Participant Registration Form
General Information
First Name
Surname
Age
Suburb
Contact Number
Email
How did you find out about us?
Emergency Contact Information
Emergency contact
Phone
Emergency contact’s relationship to you
Preferred Communication Method
Preferred Communication Option
Phone
Email
About You
What do you hope to gain from this program
What are some of your favourites activities or things to do in your free time? ( e.g hobbies, sports, interests)
Can you commit to attending the program every Thursday from 5:30 PM to 8:30 PM
Yes
No
Maybe
Below are checkboxes for both the North and South Hubs which will be alternating each week. Please check the box of the days you like to attend and if you would like to participate in the optional activities (Optional Activities may incur out of pocket costs):
*
Thursday, 10 October 2024 - Bentley Hub (Unit 1/21 Catherine St, Bentley WA 6102 Australia)
Thursday, 10 October 2024 - Optional Activity - Mini Golf - $10 Per Person
Thursday, 17 October 2024 - Inglewood Hub - (1&2/885 Beaufort St, Inglewood WA 6052)
Thursday, 17 October 2024 - Outdoor Activity - Finska - Free
Thursday, 24 October 2024 - Bentley Hub (Unit 1/21 Catherine St, Bentley WA 6102 Australia)
Thursday, 24 October 2024 - Optional Activity - Escape Room - $55 Per Person
Thursday, 31 October 2024 - Inglewood Hub - (1&2/885 Beaufort St, Inglewood WA 6052)
Thursday, 31 October 2024 - Outdoor Activity - Kubb - Free
Thursday, 7 November 2024 - Bentley Hub (Unit 1/21 Catherine St, Bentley WA 6102 Australia)
Thursday, 7 November 2024 - Optional Activity - Bounce - $20.50 Per Person
Thursday, 14 November 2024 - Inglewood Hub - (1&2/885 Beaufort St, Inglewood WA 6052)
Thursday, 21 November 2024 - Bentley Hub (Unit 1/21 Catherine St, Bentley WA 6102 Australia)
Thursday, 21 November 2024 - Optional Activity - Bowling - $16.90 Per Person
Thursday, 28 November 2024 - Inglewood Hub - (1&2/885 Beaufort St, Inglewood WA 6052)
Thursday, 28 November 2024 - Outdoor Activity - Sports Day - Free
Thursday, 5 December 2024 - Bentley Hub (Unit 1/21 Catherine St, Bentley WA 6102 Australia)
Thursday, 5 December 2024 - Optional Activity - Laser Tag - $16.90 Per Person
Thursday, 12 December 2024 - Inglewood Hub - (1&2/885 Beaufort St, Inglewood WA 6052)
Consent
Program Eligibility:
The Teen Night Out Program is specifically designed for teens with disabilities. However, acceptance into the program is subject to evaluation by Life Purpose Australia & Dynamic Support WA to ensure that the program is a suitable fit for the participant's needs.
Communication
: By providing your contact details, you consent to being contacted by Life Purpose Australia & Dynamic Support WA for the purpose of program coordination, scheduling, and updates related to
The Teen Night Out Program
.
Confidentiality
: Life Purpose Australia & Dynamic Support WA are committed to protecting your privacy. Personal information
provided on this form will be used solely for program-related communication and coordination and will not be shared with third parties without your explicit consent.
Photography and Media
: You acknowledge that photographs or videos may be taken during program activities. Life Purpose Australia & Dynamic Support WA reserves the right to use these images for promotional and marketing purposes. If you have concerns regarding the use of your or your child's image, please notify us in writing.
Program Changes:
Life Purpose Australia & Dynamic Support WA reserves the right to make changes to the program schedule,
format, or location as deemed necessary. Participants will be notified of any significant changes in a
timely manner.
Health and Safety
: Participants are responsible for disclosing any relevant health information, including specific needs related to disabilities, that may impact their participation in program activities. Life
Purpose Australia & Dynamic Support WA will take reasonable steps to accommodate and ensure the health and safety of
participants during program sessions.
By
submitting this form, you confirm that you have read, understood, and agreed to the terms outlined in
this disclaimer.
*
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