Youth, Sport and Recreation Deregistration Form

This form is to deregister a child/children in the Central Desert Regional Council YSR program by parents/guardians.

NOTES:

Submitting this form doesn't mean that your child can't be involved in the CDRC YSR program.
This form is also available in paper form at YSR forms.
You can reregister your child at any time by going to this form.

Parent/Guardian details

Parent/Guardian Name: *

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Parent/Guardian Address:*

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Parent/Guardian Phone:*

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Parent/Guardian Email:

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Child one details

Primary community:*

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Child's Name: *

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Child's date of birth:*

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Would you like to add another child?

Yes

No

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Child two details

Primary community:*

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Child's Name: *

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Child's date of birth:*

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Would you like to add another child?

Yes

No

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Child three details

Primary community:*

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Child's Name: *

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Child's date of birth:*

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Would you like to add another child?

Yes

No

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Child four details

Primary community:*

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Child's Name: *

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Child's date of birth:*

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Note: if you want to add another child, please submit this form first and then resubmit it with the extra child/ren.

Declaration

I, *

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of *

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I don't agree for the child/children named above to be filmed/recorded/photographed and appear in visual and/or audio recordings which can be used in advertisements, documents, social media and other promotional material published by the Central Desert Regional Council.
I don't give permission for the name/s of the child/children named above, and visual and/or audio recordings of the child/children named above, to be used in advertisements, documents and other promotional material published by the Central Desert Regional Council.
I understand that this will not exclude my child/children from participating in the CDRC YSR program.
This Agreement is made under the laws of the Northern Territory, and any dispute can be taken for resolution by the courts in the Northern Territory.

Your Signature*

Sign Above

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CAPTCHA*

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