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Privacy
Moreland City Council acknowledges and respects the privacy of individuals. Personal information collected on your teen’s enrolment form
and during that enrolment, including health and sensitive information, is collected, retained and used for the purpose of establishing and
maintaining your teen’s enrolment, processing financial payments (via financial institutions) and benefits where applicable. By entering
into this agreement, you agree that, to the extent reasonably necessary to enable provision of your teen’s enrolment and in conducting the
service, Moreland City Council, its related entities, and their contracted service providers including Federal, State and Local Government
Agencies covered by law, may be recipients of such information.You have the right to access personal information protecting yourself
in accordance with the Commonwealth Privacy Act (Amended 2001). The Moreland City Council Privacy Policy is available online at
www.moreland.vic.gov.au. You may receive communications from the Active Moreland from time to time to update you on matters relating
current programs through a variety of means of communication including mail, email, sms and telephone.
Service information
•
•
•
•
•
•
•
The Teenage Holiday Program is open to young people in year 7, 8 and 9 who live or go to school in Moreland.
Young people not currently attending school are still eligible to attend.
If you have a young person with special needs please contact the service to discuss the needs of your teen and participant. There
are a small number of places available for participants with low to moderate additional needs.
Active Moreland and staff reserve the right to send unwell children/teenager home.
Please ensure your child/teenager arrives at the pick up points at the specified time so that the schedule can be adhered to.
Please ensure that you pick up your child/teenager at the time designated for your location. Active Moreland will endeavour to arrive
at each location on time but may at times arrive late due to unpredictable traffic issues.
Please refer to flyer or www.activemoreland.com.au for pick up locations.
What to bring
•
•
•
Teenagers should be in suitable clothing for all planned activities and weather conditions. This includes runners, comfortable
clothing, hat, sunscreen, jackets and swimming gear for water activities.
Active Moreland recommend that participants bring a nutritious lunch, including enough snacks and drink for the day. See program
information for details of which days have an option to purchase food. Any food purchased is at an additional cost to the participant.
Parents who require medication to be administered to their teen during the program, please bring along medication with instructions
for staff, incase administration of medication is needed. Only medication with a pharmacists dispensing label outlining the teen’s
name, dosage, name of medication and current date will be administered.
Teenage Holiday Program
What not to bring
•
•
All Active Moreland Holiday programs are nut free zones. NO peanut butter, nuts or nut products are to be sent with your teen.
Please ensure you review all foods that you are providing for your teen.
We recommend that no valuable items from home including electronic games and devices, jewellery etc are brought to and used in
the program. Active Moreland holds no responsibility for the loss or damage to any such equipment.
Step 3: Payment
I wish to pay by
Cash
Credit Card
Credit card payments Select
Visa
/
$
Mastercard
Card holder’s name
Expiry date ChequeAmount to be paid
EFTPOS
CVV No.
Credit card number
Card holder’s signature
To protect your personal information, this form cannot be emailed, scanned or faxed to the centre, this form must be returned to the centre in person.
Step 4: Declarations
Step 4: Declarations
I, the undersigned approve the enrolment and agree to abide by the rules and conditions of Active Moreland’s Teenage Holiday Program
and meet any cost attached hereto. This includes no alcohol or drug possession or consumption, no smoking, no behaviour or actions
which risk the health and safety of workers or other participants in the program, and no use of offensive or abusive language directed
towards program participants, workers or anyone who comes in contact with the program. In the event of any unforseen accident or
illness I authorise the Teenage Holiday Program staff to obtain such medical assistance as is required and agree to meet any expense
attached thereto. I hereby authorise my child/teenager to participate in the program.
I give permission for photos and/or video to be taken of my child by program staff for the purposes of
promotion of the program.
Yes
No
Parent/Guardian name
Parent/Guardian signature
Date
Participant’s signature
Date
/
/
/
/
Payment type
Including young people who are not currently attending school
Autumn April 1 – April 10 2015 Bookings open now!
This section is for office use only
Entered on the THP participant database
Fun and empowering activities for Year 7, 8 and 9’s
Yes
No
Amount paid $
DateStaff
Active Moreland Teenage Holiday Program Booking Form 2015
Confirmed
Yes
No
Come in:
Coburg Leisure Centre – Bridges Reserve, Bell St, Coburg, 3058
Fawkner Leisure Centre – 79/83 Jukes Rd, Fawkner, 3060
Brunswick Baths – 14 Dawson St, Brunswick, 3056
P: 03 9354 3504
F: 03 9354 8062
E: programs@activemoreland.com.au
W: activemoreland.com.au
Area
Coburg Brunswick Glenroy Fawkner Pick up / drop off times and locations
Address Pick-up Drop-off
Coburg Leisure Centre Bridges reserve, Bell Street
Brunswick Library, Dawson Street, Brunswick
on Dawson Street next to the library awning
Cnr Hartington St & Glenroy Road across the road from Glenroy Station
Fawkner Leisure Centre 79-83 Jukes Road
9am 3pm
8.30am 3.30pm
8.40am 3.30pm
8.50am 3.40pm
Week 1
Week 2
Wednesday 1 April
Luna Park
Tuesday 7 April
Fun City and Swimming
Option to bring lunch or purchase at own cost.
Option to bring lunch or purchase at own cost.
Experience Melbourne’s ultimate destination for fun!
Unlimitedrides including: The Spider, Enterprise, Ferris Wheel,
Twin Dragon and Scenic Railway.
Thursday 2 April
Movies and Intencity
Catch a movie at Reading Cinemas in Epping then head to
Intencity for an hour of unlimited video games.
Option to bring lunch or purchase at own cost.
Go Karts, Laser Force and more at Fun City Sunshine, then to
Coburg Leisure Centre for a swim in the heated indoor pool.
Bring bathers and a towel.
Thursday 9 April
Horseriding
Trail ride through the beautiful countryside at Uncle Nev’s in
Whittlesea. No experience necessary with experienced staff
leading the group.
Option to bring lunch or purchase at own cost.
Friday 10 April
YMCA Lake Dewar
Excursion
Head to YMCA’s Lake Dewar recreation camp for some fun and
challenging activities, such as: Canoeing, Flying Fox, Tunnelling
and Archery. Activities may vary depending on the weather, but
bring a towel and change of clothes just in case.
Must bring own lunch. No options to purchase food.
General Information:
TEENAGERS WITH ADDITIONAL NEEDS
Active Moreland welcomes participants with low to moderate
additional needs and independent mobility to the program and
has a limited number of spaces available for each day. For
further information and to discuss the possibility of your teen
attending one or more of the days please contact the program
coordinator. Please note that acceptance in the program is not
guaranteed if the program coordinator is not satisfied that the
participant needs can be met.
PROGRAM LEADERS
Program Leaders are First Aid, CPR and Anaphylaxis trained.
All leaders hold a Working with Children Check Card.
BOOKINGS
Bookings are only accepted once a 2015 enrollment form has
been completed, signed and returned with payment details
confirmed. Please ensure you have completed ALL sections
of the enrollment form making sure you sign and understand
the terms and conditions. Bookings are not finalised until full
payment has been received.
HORSE RIDING WAIVER
A seperate waiver form must be completed for the Horse riding
activity. This will be available on the Active Moreland website
and emailed to you upon booking.
PROGRAM SPECIFICS:
• This program is offered to Year 7, 8 and 9’s who live or go
to school in the Moreland area
• Bookings and pre payment are essential to confirm your
teen’s place in the Teenage Holiday Program.
• Participants will be fully responsible for any valuables they
bring to the program. We recommend that participants do
not bring any valuables such as electronic devices,
jewellery etc that are not necessary for the program.
• Please ensure your teen arrives at the pick up points at the
specified time so that the schedule can be adhered to.
OTHER INFORMATION:
Management reserves the right to make changes to the
program without notice. This includes cancellation of the
program due to insufficient numbers or inclement weather.
Teenages are expected to be co-operative, courteous, and
respectful towards other participants and leaders, participate in
activities, and to respect the environment we are in.
We reserve the right to send a teenager home for serious
breach of this policy i.e the teenager is endangering the
physical or emotional safety of others and/or has persistently
failed to respond to discussions regarding unacceptable
behaviour. There will be no refunds for young people asked to
leave the program.
Active Moreland Teenage Holiday Program: Booking Form
• Booking
An
Enrolment
Form must
be completed
for each
participant
Active
Moreland
Teenage
Holiday
Program:
Booking
Form Forms can be downloaded online at
www.activemoreland.com.au or contact (03) 9354 3504 or email
Booking
Forms can be downloaded online
atavailable at each centre
programs@activemoreland.com.au.
Forms
www.activemoreland.com.au
or contact (03) as
9354
or email
Please book early to avoid disappointment
we 3504
are limited
programs@activemoreland.com.au.
Forms
also available
in the amount of places we can offer.
This booking
will notatbe
each
centre.until Enrolment and Booking Forms are completed,
confirmed
• Please
book
early
to avoid
we are limited
submitted
and
a place
hasdisappointment
been allocated.as
A waiting
list will be
intaken
the amount
places
we can
offer. This booking will not be
for eachofday
in case
of cancellations.
• confirmed
Enrolment
are completed,
If a place until
is allocated,
youand
willBooking
receive aForms
confirmation
of booking
submitted
full payment
has been
received.
(once full and
payment
is received)
via email.
If you do not receive
• Once
paymentplease
is processed
booking
is confirmed,
if youor
confirmation,
contactyour
Chris
Arena on,
03 9354 3504
are
unsure of this, please contact Chris
Arenaallow
on, 03
9354 3504
programs@activemoreland.com.au.
Please
2 working
days
or
programs@activemoreland.com.au.
before
making contact once you have submitted your form.
•• Please
Pleasenote
noterefunds
refundswill
willnot
notbe
beissued
issuedfor
forabsent
absentdays
daysdue
duetoto
sickness
sicknessor
orany
anyother
otherreason.
reason.
and returned to Active Moreland prior to the booking form being able
Form
must be completed for each participant
toAn
beEnrolment
accepted and
processed.
and returned to Active Moreland prior to the booking form being
able to be accepted and processed.
Details to return the form are:
Details to return the form are:
Email: programs@activemoreland.com.au
Email: programs@activemoreland.com.au
Fax:
Fax:03
039354
93548062
8062
Post:
Post:Coburg
CoburgLeisure
LeisureCentre,
Centre,Bridges
BridgesReserve,
Reserve,Bell
BellSt,
St,Coburg,
Coburg,3058
3058
•
•
Hand
Handininatatone
oneof
ofthe
theActive
ActiveMoreland
MorelandLeisure
LeisureCentres:
Centres:
CoburgLeisure
LeisureCentre
Centre––as
asabove
above
Coburg
FawknerLeisure
LeisureCentre
Centre––79-83
79-83Jukes
JukesRd,
Rd,Fawkner,
Fawkner,3060
3060or
or
Fawkner
BrunswickBaths
Baths––14
14Dawson
DawsonSt,
St,Brunswick,
Brunswick,3056
3056
Brunswick
How to Book Step 1: Personal Information
How
to Book Step 1: Personal Information
Parent/Guardian Name
Contact Number
Parent/Guardian Name
Contact Number
Address
Suburb
Postcode
Address Suburb
Postcode
Email
Teen’s School
Email
Teen’s School
Teen’s Full Name
DOB
/
/
M
Teen’s Full Name
DOB
/
/
M
Second Emergency Contact Name
Contact Number
Second Emergency Contact Name
Contact Number
Teen’s medical details: Does the particpant have any illness, condition or disability? (attach details)
Teen’s medical details: Does the particpant have any illness, condition or disability? (attach details)
F
F
Is the participant currently taking any medication? (please specify)
Is the participant currently taking any medication? (please specify)
Is medication assistance required?
Yes
No
Is medication assistance required?
Yes
No
Does the participant have any allergies (including medications)? (please list)
Does the participant have any allergies (including medications)? (please list)
General permissions
• Can the participant swim? Yes
Are there any details not included in this form that may be
important for a person who supervises this young person
to know?
• I give permission for this young person
General permissions
• Are there any details not included in this form that may be
to see movies that are “M’ rated:
Yes
No
• Can the participant swim? Yes
Poor
Not at all
important for a person who supervises this young person
• I give permission for this young person to depart from the
to*know?
Please advise the program coordinator if there are any
• I give permission for this young person
drop off point unsupervised after the program is over:*
known persons who this young person should NOT be
to see movies that are “M’ rated:
Yes
No
released into the care of.
Yes
No
• I give permission for this young person to depart from the
* Please advise the program coordinator if there are any
drop off point unsupervised after the program is over:*
known persons who this young person should NOT be
released
into
the care
Step
days would your teen attend? (Please
select
which
days of.
you would like your teen booked in.)
Yes 2: Which
No
Week 1
Poor
•
Not at all
Thursday 10 - Wednesday 16 April
Thurs 10 April
Fri 11 April
Mon 14 April
Tues 15 April
Wed 16 April
Step
Which daysHorseriding
would your teen attend?
select which
days you
would like your
teen booked
in.)
Movies &(Please
Bowling
Luna2:Park
Outdoor
Action
Kemizo
& Swim
Cost $ 30
Cost $ 45
Cost $ 20
Cost $ 20
Cost $ 25
Wednesday
1GAprilF – Friday
10
C
B
C
B April
G
Wed 1 April
Thurs 2 April
Week 2
Luna Park
C
B
Cost $ 20
Movies and Intencity
C
B
G
G
Total cost $
Total cost $
F
F
Cost $20
C
B
Cost $ 20
C
B
C
B
G
F
Tues 7 April
F
G
F
Cost $32
C
B
Cost $ 25
C
B
B
G
F
G
Cost $45
C
B
Cost $ 25
B
G
F
Lake Dewar YMCA
Tues 21 Jan
F
C
Fri 10 April
Horse riding
Wed 16 April
G
C
Thurs 9 April
Fun City and Swim
Tues 15 April
Mon 14 April
Cost $30
F
Wed 22 Jan
G
F
Cost $25
C
Cost $
B
20
G
F
G
F
C
B
G
F
C
B
G
F
Pick up locations C: Coburg B: Brunswick G: Glenroy F: Fawkner
Refer to brochure for pick up location addresses.
Pick up locations C: Coburg B: Brunswick G: Glenroy F: Fawkner
Refer to brochure for pick up location addresses.