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Safe Cycle Workshop

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Safe Cycle Workshop

As part of the Victorian State Government's Walk to School program, All Terrain Cycles and Mansfield Shire Council are hosting a FREE Safe Cycle session for all primary school aged children.

Please complete the following registration form for your child to participate on the day.

Parent/Guardian of Participant/s

First Name *

Last Name *

Preferred Communication Method(s)

Phone

Email

Phone Number *

Email *

Emergency Contact Person On The Day

First Name *

Last Name *

Phone Number *

Name Of Participant 1

First Name *

Last Name *

Birth Date *

Day

Month

Year

Street Address *

City *

Postal Code *

State/Province *

Which School Does Your Child Attend? *

Mansfield Primary School

St Mary's Primary School

Mansfield Steiner School

Merrijig Primary School

Jamieson Primary School

Home Schooled in the Mansfield Shire

What Year Level is Your Child In? *

Does Your Child Have A Bike & Helmet To Bring On The Day? *

YES

NO

Child's Level of Ability *

NOT able to ride independently

Able to ride but developing skills

Able to ride independently

Experienced independent rider

Any Medical Conditions We Should Be Aware Of? *

Yes

No

Please List The Medical Conditions *

Do You Want To Register Another Child? *

YES

NO

Name Of Participant 2

First Name *

Last Name *

Birth Date *

Day

Month

Year

Street Address *

City *

Postal Code *

State/Province *

Which School Does Your Child Attend? *

Mansfield Primary School

St Mary's Primary School

Mansfield Steiner School

Merrijig Primary School

Jamieson Primary School

Home Schooled in the Mansfield Shire

What Year Level is Your Child In? *

Does Your Child Have A Bike & Helmet To Bring On The Day? *

YES

NO

Child 2 Level of Ability *

NOT able to ride independently

Able to ride but developing skills

Able to ride independently

Experienced independent rider

Any Medical Conditions We Should Be Aware Of? *

Yes

No

Please List The Medical Conditions *

Do You Want To Register a Third Child? *

YES

NO

Name Of Participant 3

First Name *

Last Name *

Birth Date *

Day

Month

Year

Street Address *

City *

Postal Code *

State/Province *

Which School Does Your Child Attend? *

Mansfield Primary School

St Mary's Primary School

Mansfield Steiner School

Merrijig Primary School

Jamieson Primary School

Home Schooled in the Mansfield Shire

What Year Level is Your Child In? *

Does Your Child Have A Bike & Helmet To Bring On The Day? *

YES

NO

Child 3 Level of Ability *

NOT able to ride independently

Able to ride but developing skills

Able to ride independently

Experienced independent rider

Any Medical Conditions We Should Be Aware Of? *

Yes

No

Please List The Medical Conditions *

Do You Want To Register a Fourth Child? *

YES

NO

Name Of Participant 4

First Name *

Last Name *

Birth Date *

Day

Month

Year

Street Address *

City *

Postal Code *

State/Province *

Which School Does Your Child Attend? *

Mansfield Primary School

St Mary's Primary School

Mansfield Steiner School

Merrijig Primary School

Jamieson Primary School

Home Schooled in the Mansfield Shire

What Year Level is Your Child In? *

Does Your Child Have A Bike & Helmet To Bring On The Day? *

YES

NO

Child 4 Level of Ability *

NOT able to ride independently

Able to ride but developing skills

Able to ride independently

Experienced independent rider

Any Medical Conditions We Should Be Aware Of? *

Yes

No

Please List The Medical Conditions *

Photography and Recording Consent *

To help us comply with the Privacy and Data Protection Act 2014 (VIC), Council would like your consent before we take a photograph or recording of you or your child for whom you are responsible. The photograph or recording may be sent out to the media for promotional purposes and publication. It may also be used in our publications or those of our partners, or used in exhibitions or on our website or social media accounts to promote our services and events. Please note that websites and social media accounts can be seen throughout the world and not just in Australia where Australian law applies. Declaration * I have read and understood the information above and give permission for Mansfield Shire Council, its partners and the media to take and/or use the photographs/recordings of me or my child at this event.

Yes. Mansfield Shire Council has my consent

No. I do not consent

Parent/Guardian Consent

Signer Name *

Leave this field blank

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Last Updated: Thursday, 29 August, 2019 - 12:26

Contact us

Phone: (03) 5775 8555

TTY users phone 133 677

then ask for (03) 5775 8555

Find out more about National Relay Service

View all contact details and opening hours

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Email: council@mansfield.vic.gov.au

Address: 33 Highett Street
Mansfield, VIC 3722

Postal: Private Bag 1000
Mansfield, VIC 3724

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