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Welcome to Power Neighbourhood House

Online Enrolment Form

Fields marked * are mandatory

PERSONAL DETAILS

FIRST NAME:   *      SURNAME:   * 

ADDRESS:    * 

SUBURB:   *          POSTCODE:  * 

EMAIL: * 

CONFIRM EMAIL: * 

A copy of this application will be sent to the supplied email address

PHONE NUMBERS:
Phone 1* *
Phone 2  
EMERGENCY CONTACT

FULL NAME: * 

RELATIONSHIP: * 

PHONE NUMBER: * 

PRIVACY INFORMATION

The information on this form is collected for the sole pupose of Amaroo Neighbourhood Centre Inc. to identify its participants for safety and insurance purposes. It is a legal requirement for the Centre to have the details of all participants enrolled in the Centre. If you do not wish to fill out this form, you will not be covered by our Public Liability Insurance and the Centre would be unable to permit you to undertake a course or access the Centre. Your personal information is seen only by the Office Staff. It will not be disclosed to a third party without your consent, unless we are required or authorised to do so by law or other regulations. Our class list, which only has your name and phone number on it, is kept in perpetuity for insurance purposes. By signing this form you are giving consent to the information to be seen by staff members of the Centre. At any time you are able to gain access to the information held about you and to make changes if necessary.

COURSE DETAILS
Course Name (1):
Course Name (2):
MEDICAL DETAILS

Do you have a medical condition or disability that staff need to know about?

If YES, please provide details:

We aim to ensure that our facilities meet the needs of our participants. If you have an illness, injury or disability that you believe it is important we know about, please provide details. All information collected is solely for the purpose of ensuring your needs are met both in class and in the event of a medical emergency. This information is not disclosed to any person without your consent.

CONSENT

Submitting this form confirms my consent to Power Neighbourhood House seeking, or where appropriate, administering such emergency treatment as is reasonably necessary.  My consent also extends for the Centre’s staff to have access to my full name, phone number, medical and emergency contact details in order to ensure that the most appropriate action can be taken in the event of such an emergency.

Automatic membership is applied when you enrol in this course entitling you to vote at the Annual General Meeting and attend the Christmas Party.

 

coffee  Please feel free to drop in any time, we are open for a cuppa and a chat. There is always someone friendly around. smiley

Power Neighbourhood House gratefully acknowledges
Monash City Council
Wheelchair Access
Victorian Government