EmailMe Form - Corrugated Iron Membership form

Corrugated Iron Membership form
Join CIYA annually to participate in the workshop program

Name *

Email *

Please contact me about news and events *

Yes

Home phone number

Mobile phone number *

Address

Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

Do you identify as Aboriginal or Torres Strait Islander? YES/NO *

Workshop/s attending *

Emergency contact: Name/ relationship / mobile number *

MEDICAL:
Do you have any allergies or medical conditions?
Are you taking any medications? Is there anything we should know about? *

In the event of an emergency, illness or accident, when unable to contact parents or authorized emergency contact, I consent to the administration of any medical, surgical
or dental procedures, including anaesthetic, as recommended by a qualified medical

YES

Please ensure that both tutors and the Executive Producer or Workshop Coordinator are advised about any matter that may affect your (or your childs) ability to attend or participate in any aspects of a workshop. You may make notes here or contact the offi

PERMISSION FOR PUBLICITY:
I hereby consent to my being photographed/filmed for documentation and publicity purposes. I further consent to my photograph, name and age being used for documentation and publicity for the organisation, should this be required

YES

PRIVACY STATEMENT:
Corrugated Iron Youth Arts collects the information on this form to add your name and contact details on our participant lists. Corrugated Iron uses these lists (i) to contact participants or families in case of emergency or change of

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