1. All participants of the Civic Centre Youth Space need to fill out an annual Membership Form.

2. Young People under 18 years of age will require a responsible adult to provide consent.

Participant Details
DOB *
M F Other
This will be used to send program information.
Emergency Contact

Please answer Yes or No. If answered yes, please include details.

Medical Questions and Personal Information
If yes, please detail if the plan self-managed.
Please include school / university name under details.

The Town of Gawler sometimes uses images, videos and other marketing materials to promote what we do through different media forms including on social media. All material remains the sole property of the Town of Gawler.

Photographic Release Consent
I provide Photographic Release Consent
Terms and Conditions – Youth Space
Terms and Conditions

Disclaimer: Council takes all care and responsibility for this program in accord with its duty under
relevant Local Government, WHS and Child Protection legislation.

Please use either the Assent or Consent section below to finalise the form.

Assent - participants under 18 years of age.

Assent
This is acknowledgement that you give assent as outlined above.
Date *

Consent - To be signed by participants over 18 years of age, or a responsible adult of participant under 18 years of age. As the participants responsible adult.

Consent
I give consent as outlined above.
Date *