Details

School Vacation Program

If you are human, leave this field blank.

Contact details

First Name *

Middle Name

Last Name *

Date of Birth *

Age *

Gender *

Residential Address *

Suburb *

Postcode *

Preferred Contact Number

Alternate Contact number

Email Address

I would like to join the AYC mailing list and recieve regular updates on local activities and opportunities *

Yes

Photo Authorisation

I authorise Auburn Youth Centre staff and volunteers to take my photo for use in AYC publications and for purposes to promote the centre and related programs, and understand these photos will be used on the Internet.

Medical Information

Allergies *

Please separate each individual entry with a comma or enter N/A if applicant possesses no known allergies

Are you asthmatic? *

Yes

Medicare Number

Medicare Card Number

Special Dietary Requirements (e.g. lactose intolerant, gluten free)

Other Medical Information

Enter any other relevant medical information

Emergency Contact

Emergency Contact Name *

Emergency contact must be over the age of 18

Relationship *

Applicant's relationship with emergency contact

Primary contact number *

Emergency contact's primary contact number (landline or mobile)

Secondary contact number *

Emergency contact's secondary contact number (landline or mobile)

Demographic Information

Demographics

Receiving government benefit

Low income earner (household)

Unaccompanied minor

Living within the Cumberland LGA

Aged between 12-24 years old

Coming up at AYC

Interested in attending one of our events? Take a look at what is available here

Events

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