1. Art and Diseño

January 2015 Free School Holiday Programme from
Volunteering Otago and the New Zealand Red Cross
Volunteer Form
This is a sign up form for the January 2015 Free School Holiday Programme from Volunteering Otago
and the New Zealand Red Cross! Activities will include; making food for the food bank, helping rescue
animals, student radio shows, working on community gardens, Red Cross activities, and much more!
The programme is 100% free and 100% fun!
All fields are required to be filled in.
Young people must be no younger than 11 years upon date of intake.
The first week's programme is located at the Dunedin Red Cross Building at 31
York Place and runs 19-23 January. Ages 14 - 17 years
The second week's programme is located at the Dunedin Red Cross Building at 31
York Place and runs 26-30 January. Ages 11 -13 years
Each programme runs Monday to Friday, 10AM to 3PM.
Young people may choose, and be guaranteed entry into only one of these weeks.
Volunteer Name____________________________________________________
Address__________________________________________________________
________________________________________________________________
Phone number_____________________________________________________
Email____________________________________________________________
Your Age?________________________________________________________
How did you hear about the holiday programme?_________________________
Are there any activities you are excited about?___________________________
Any allergies/medical considerations?___________________________________
What don’t you eat?________________________________________________
Anything else we should know? _______________________________________
Volunteering Otago, Level 1, Dunedin Community House, 283-301 Moray Place, Dunedin 9016
Phone: 03 471 6206
Tollfree (Otago area only): 0800-865-268
Email: [email protected]
Website:www.volunteeringotago.org.nz
Volunteer signature ________________________________________________
Parents/ Guardian name(s)___________________________________________
Parent/Guardian emergency contact numbers
Home___________________________________________________
Work ___________________________________________________
Cell Phone _______________________________________________
Email___________________________________________________
Preferred mode of contact___________________________________
Who is authorised to collect the young person?*__________________
*If the young person in your care will be making his/her own way to/from the
programme, we also need written permission from you.
_______________________________________________________________________
_________________________________________________________
I give permission for my son/daughter to participate in the Volunteer Otago School
Holiday Programme. To the best of my knowledge my daughter/son has no medical or
physical hindrance (not mentioned above) that is likely to prove detrimental to her/him,
or others during these activities.
Parents/ Guardian signature__________________________________________
Date:____________________________________________________________
Week chosen to attend: (Please circle one):
19-23 January
26-30 January
Should you have any further questions, please do not hesitate to contact me.
Heather Moore, Volunteering Otago
03) 471 6206 [email protected]
Photograph Permission Form
Dear parent/caregiver
We will be taking photographs of Volunteering Otago workers and participants in the
upcoming School Holiday Programme between the 5th and the 16th of January 2015.
Volunteering Otago would like your permission to use any images taken of your child, in
various publications. Permission relates to Volunteering Otago official or endorsed
promotional material only. We need to know whether you are happy for us to use your child's
image for these purposes and in these formats. Therefore, it would help us greatly if you
would tick (as many as you wish) the following, where you consent to the use of pictures of
your child.
Publication:
Please tick
Paper based documents/publications: such as the annual report,
newsletters, funding applications
Internet media: such as our website, facebook page
Electronic documents: such as presentations to the community
News media: such as newspapers
Should you choose to withdraw your consent at any time, then please contact us and we will
respect your wishes as quickly as possible (i.e. remove images where possible).
Declaration
I grant permission for photographs of my child to be sued in the formats indicated above.
Name of Child: ____________________________________________________________
Age of Child ______________________________________________________________
Your Name: ______________________________________________________________
Signature: _______________________________________________________________
Child's Signature (if over 12 years): ___________________________________________
Date: _______/_______/_______
Should you wish to view the photographs/images of your child, copies will be made available
at your request.
Broadcast Release Form
Dear parent/caregiver
As part of their participation in the upcoming Volunteering Otago Breakaway School Holiday
Programme, your child will have the opportunity to be broadcast on Oar 105.4 FM Otago
access radio (previously Toroa Radio). This broadcast will be no longer than 30 minutes,
sometime between 5th of January and 16th of January 2015.
Volunteering Otago would like your permission for your child to be part of this broadcast.
Permission relates to the Volunteering Otago's School Holiday Programme broadcast only.
The content of this broadcast is decided on and written by the Volunteering Otago School
Holiday Programme participants (within broadcasting standards), and generally involves
reports on activities completed by the participants during the programme.
If you have any further questions, please contact Heather Moore at Volunteering Otago.
Should you choose to withdraw your consent at any time, then please contact us and we will
respect your wishes as quickly as possible.
Declaration
I grant permission for my child to be part of a radio show broadcast on Oar FM between 5th of
January and 16th January 2015.
Name of Child: ____________________________________________________________
Your Name: ______________________________________________________________
Signature: _______________________________________________________________
Child's Signature (if over 12 years): ___________________________________________
Date: _______/_______/_______