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EQYLP Registration Form

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YOUTH LEADERSHIP PROGRAM PARTICIPANT REGISTRATION AND ACKNOWLEDGEMENT FORM Hands of Change Limited ACN 610 884 583 ABN 41 610 884 583

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This is an important document which affects your legal rights and obligations Read it carefully and do not sign it unless you are satisfied that you understand it If you have any questions please ask a Hands of Change Limited representative THE BUSINESS AND ACTIVITIES Hands of Change Limited offers an opportunity for the participant to interact with horses on the ground and take part in a variety of horse related activities Activities might be with or without horses loose in an enclosed area such as a round pen or arena or in a large open paddock with a number of horses or with one horse on the end of a halter and lead rope There is no riding offered as part of this program

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Participant registration acknowledgement form This form is for the Equihands Youth Leadership Program Use a black or blue pen and print clearly Print X in the appropriate boxes Section A PARTICPANT DETAILS 1 What is the participant s name First given name Surname or family name 2 What are the participant s contact details Address Postcode Home Number Mobile Number Email Address 3 Participant s date of birth Day Month Year 4 Participant s country of birth Country 5 Participant s gender Select only one Female Male Non binary DECLARATION by parent guardian I do I do not give consent to Hands Of Change Limited to record and use my child s personal details and to notify me of future Hands Of Change programs Hands of Change Limited ACN 610 884 583 ABN 41 610 884 583

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Participant registration acknowledgement form This form is for the Equihands Youth Leadership Program Use a black or blue pen and print clearly Print X in the appropriate boxes Section B PREFERRED PROGRAM SERIES There are six program dates to choose from with each program series being delivered one afternoon a week for two hours 4 00pm to 6 00pm over four weeks Each week will explore a leadership skill that can then be applied to community engagement Week One Observing the world around us Week Two Listening and communication Week Three Self awareness Week Four Team work Final Presentation Group to present their community challenge to council 6 What program would you like to register for Select only one Week One Week Two Week Three Week Four Series 6 2020 Series 7 2020 Week One Week Two Week Three Week Four Week One Week Two Week Three Week Four 4 March 11 March 18 March 25 March IV ER EL D IV ER EL D IV ER EL D 16 October 23 October 30 October 6 November ED Series 4 and 5 2019 Week One Week Two Week Three Week Four 14 August 21 August 28 August 4 September ED Series 2 and 3 2019 Week One Week Two Week Three Week Four ED Series 1 2019 13 November 20 November 27 November 4 December Please indicate time preference 22 April 29 April 6 May 13 May 10 00am to 12 00noon 4 00pm to 6 00pm Section C EMERGENCY CONTACT DETAILS 7 Who is your emergency contact for the participant First given name Surname or family name Home Number Mobile Number Relationship to participant Hands of Change Limited ACN 610 884 583 ABN 41 610 884 583

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Participant registration acknowledgement form This form is for the Equihands Youth Leadership Program Use a black or blue pen and print clearly Print X in the appropriate boxes Section D MEDICAL DETAILS 8 Does the participant have any pre existing injury or medical condition that may limit them from performing specific tasks No Yes If yes please complete the following section below so we can assist you with your needs 9 Any pre existing injury or medical condition No Yes Injury or medical condition 10 Any allergies No Yes Allergies 11 Any dietary requirements No Yes Dietary requirments 12 Any special care for any of the above during participation No Yes Please provide details 13 Any specific medications No Yes Please provide details and correct dosage Hands of Change Limited ACN 610 884 583 ABN 41 610 884 583

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Participant registration acknowledgement form This form is for the Equihands Youth Leadership Program Use a black or blue pen and print clearly Print X in the appropriate boxes Section D TRANSPORT DETAILS I give permission for Hands of Change Limited to delegate a Golden Plains Shire Council staff to transport my son daughter in a council approved and insured vehicle throughout the course of the Equihands Youth Leadership program in question I understand that Golden Plains Shire Council staff will act in adherence with Child Safe Standards and Councils Youth Transport Policy I acknowledge the need for responsible behaviour and obedience of instructions on my son daughters behalf and that should my child s behaviour be deemed inappropriate I may be contacted and asked to collect him her without notice DECLARATION by parent guardian I do I do not give consent to Hands of Change Limited and Golden Plains Shire Council to transport my child during the specified program Section E PHOTO CONSENT I give permission for Hands of Change Limited to take photographs and videos of my child throughout the Equihands Youth Leadership Program in question I understand that these images videos may be used for the sole purpose of Hands of Change s advertising promotional material website and social media without acknowledgement and without being entitled to any remuneration or compensation DECLARATION by parent guardian I do I do not give consent to Hands of Change Limited to take photographs videos of my child during the specified program Section F CODE OF CONDUCT Throughout the course of my child s participation in the Equihands Youth Leadership program in question he she agrees to Behave honestly and with integrity Act with care and diligence and accept responsibility for their actions Treat everyone with respect and courtesy Behave in a way that upholds Hands of Change values and reputation Use Hands of Change resources in an appropriate manner Seek permission from the lead Hands of Change staff member before making any decisions Not make improper use of their status power or authority Not make improper use of sensitive private confidential information DECLARATION by parent guardian I do I do not agree with Hands of Change Limited program Code of Conduct Hands of Change Limited ACN 610 884 583 ABN 41 610 884 583

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Participant registration acknowledgement form This form is for the Equihands Youth Leadership Program Use a black or blue pen and print clearly Print X in the appropriate boxes Section G PARENT GUARDIAN STATEMENT ACKNOWLEDGEMENTS I acknowledge that horses can be dangerous and may behave unpredictably or in ways which may cause death injury disability or damage to persons or property I understand and acknowledge that the named participant may be injured or their personal property may be lost damaged or destroyed whilst taking part in this activity Other people may cause them injury or may damage their property or they may cause injury to other persons or damage their property They are taking part in the Activities voluntarily RISK WARNING I acknowledge that I have been warned of the risks of the named participant taking part in equine assisted learning activities and the associated interaction with horses ASSUMPTION OF RISK Notwithstanding the significant risks of physical harm and injury inherent in the Activity some of which are noted above I agree that the participant will participate in the Activity at their own risk WAIVER RELEASE AND INDEMNITY I agree to release Hands of Change Limited and its officers employees and agents from any liability arising out of any injury loss damage or death caused to me or my property or any other person arising from or in connection with the participant s participation in the Activities whether such injury loss damage or death was caused directly or indirectly by negligence breach of contract or any way whatsoever I agree to indemnify and hold harmless Hands of Change Limited and its officers employees and agents from all claims damages losses injuries and expenses arising out of or resulting from the named participant in participation in the Activities I hereby agree and consent to the young person stated overleaf participating in the Equihands Youth Leadership program I hereby give permission for Hands of Change Limited staff to supervise my child throughout the duration of the program in question and to seek appropriate professional medical intervention if deemed necessary Hands of Change Limited ACN 610 884 583 ABN 41 610 884 583

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Participant registration acknowledgement form This form is for the Equihands Youth Leadership Program Use a black or blue pen and print clearly Print X in the appropriate boxes Section H PARENT GUARDIAN STATEMENT I ACKNOWLEDGE THAT I HAVE READ THIS FORM AND THAT IT HAS BEEN EXPLAINED TO ME I FULLY UNDERSTAND ITS TERMS AND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT I SIGNED THE DOCUMENT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT MADE TO ME Signature of parent guardian Day Month Year Day Month Year Name of parent guardian Signature of witness Name of witness Section I HANDS OF CHANGE LIMITED PRIVACY STATEMENT Hands of Change Limited considers that the responsible handling of personal information is a key aspect of democratic governance and is strongly committed to protecting an individual s right to privacy Hands of Change Limited will comply with the Information Privacy Principles as set out in the Privacy and Data Protection Act 2014 Hands of Change Limited has in place a standard operating procedure that sets out the requirements for the management and handling of personal information If you have any queries regarding this Privacy Statement please contact the Privacy Officer on 61 0490 055 984 Hands of Change Limited ACN 610 884 583 ABN 41 610 884 583

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Participant registration acknowledgement form This form is for the Equihands Youth Leadership Program Use a black or blue pen and print clearly Print X in the appropriate boxes Section J OTHER COMMENTS Hands of Change Limited ACN 610 884 583 ABN 41 610 884 583

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CONTACT DETAILS info handsofchange org au 61 0 490 055 984 www handsofchange org au PROUDLY SUPPORTED BY