HomeWhat’s onEvents calendarRegistration Form Event name*Sorry, registrations are closed.Is this the first time you are registering for a MIC Youth Program?*YesNoName*Date of birth* Date Format: DD slash MM slash YYYY Are you 18 years old or older?*I am younger than 18I am 18 years old or olderDate of arrival in Australia*Home phone numberMobile phone number*Gender*MaleFemaleOtherAddress*Country of birth*Visa sub classEthnicity*(eg: Chin, Karen, Zomi)Language spoken*SchoolEmergency contactName*Home phone numberHome phone numberMobile phone number*Relationship*Language*Medical informationAllergiesOther health conditionsVideo/photograph consentOur organisation often takes photographs of young people to use in promotion of our programs, publications and in media. Do you give permission for photographs featuring your child to be used for these purposes?*YesNoParental consentParent/guardian name*Parent/guardian contact number*Overall consent* I give permission for my child to attend this program.Medical consent* I agree that in case of emergency: If my emergency contacts cannot be reached, I agree for the MIC staff member to take me/my child to a doctor or a hospital or call an ambulance for medical help. I agree that the doctor may give medical or surgical treatment which he or she believes is necessary.I agree with the MIC providing summary information to the Department of Social Services on your/your children’s (under 18 years only) demographics (e.g. residential post code, age, language spoken, COB) and the reasons why you and/or your children seek assistance from the MIC. Information supplied to DSS will not enable you be identified. The information is used to monitor the work of the MIC.Consent for your children*YesNoDo you consent to the MIC contacting you in the future for surveys/research?YesNoYou must select the options that give permission for your child to attend this program, and permission for MIC to take you/your child to a doctor/hospital in case of emergency.Gender (old data) Back to top
