Life SkillsProgram

www.bluelight.co.nz

New Zealand Blue Light

Application Pack

Goals · NZ Blue Light Ventures Youth Life Skills program

aims to be an intervention that provides positive sustainable alternatives in situations where young people are at risk of becoming offenders, victims of crime, and/or displaying anti-social behavior. The action based learning program incorporates Adventure-related Experiential Learning (AEL) methodologies to facilitate the transfer of learning and establish a more positive frame of reference purposed to initiate a process of:

· Improving the relationship between young people, their families, the community and the Police.

· Changing anti-social behaviour and preventing crime.

· Introducing young people to support systems that will help them develop positive personal, team work, and social skills.

· Exposing them to situations that require goal-setting, self-discipline, and perseverance.

· Introducing them to basic leadership skills.

RefeRReR expectations Due to the size of the program and the number of referrers that want to access the course for their young people we have set out the expectations that Blue Light has for referrers to ensure the course will be a success.These include:

· Collecting required forms in a timely fashion to ensure key timeframes are able to be met by Blue Light and the Defence Force.

· Transportation to and from the course is the responsibility of the referrer to arrange with assistance if required from the family (cost for this is not covered within the course costs).

· Payment of course costs will be invoiced to the referrer. If you have other arrangements with outside groups this is the responsibility of the referrer to organise.

· Withdrawal of applicants due to external reasons

must be reported to Blue Light Life Skills Program Coordinator. If a late withdrawal for the course is received or a young person does not attend without good reason then you may be invoiced for the course. Early notification allows Blue Light to fill the position and therefore ensuring the course is full.

· If for some reason a young person requires medical attention during the course Blue Light may pass costs onto the appropriate person, in particular pre-existing medical/health issues.

· Graduation is a particularly important part of the course and supporting the young people to be proud of what they have achieved we encourage referrers, parents and supporters to attend the graduation.

· Follow up support on a one on one basis is critical to a successful program. Blue Light expects referrers to have contact with the young people for 6 months after the course (see Referrer Handbook).

The attached application is to be completed by the referrer

· The applicant must be in the age range of the course you are applying for - course details and ages can be found at: www.bluelight.co.nz or in the latest brochure.

· Successful applicants are responsible for the cost of travel to/from the course.

· Applicants will be notified of tentative acceptance pending a medical review.

· Confirmation of enrolment onto the course is subject to approval from NZ Blue Light.

· To be considered for a course this application form must be completed in its entirety.

Combined Blue Light / NZDF YDU Participant Consent Form Page 3

YoUtH life-sKills coURse application

applicant peRsonal Details

First name Last name

Male Female Date of birth School

/ / Street number and name

Suburb Town/City Post Code/RD

Home phone Mobile

Email

REFERRER DETAILS

First name Last name

Organisation

Street number and name

Suburb Town/City Post Code/RD

Work phone Mobile

Email

PARENT / CAREGIVER / NEXT OF KIN DETAILS

First name Last name

Relationship to Applicant

Street number and name

Suburb Town/City Post Code/RD

Home phone Mobile

Email

COURSE DETAILSTell us your preferred course dates – course dates can be found at www.bluelight.co.nz or in the latest brochure.With high demand for courses we will try our best to fit the applicant into the preferred course but unfortunately this is not always possible. Cost: NZ$150 incl. GST (excludes travelling to and from the course).

Venue Start date

First course preference / /

Second course preference / /

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Pant Size S M L XL XXL

Shirt Size S M L XL XXL

Shoe Size

Combined Blue Light / NZDF YDU Participant Consent Form Page 4

GENERAL INFORMATIONPlease indicate if any of the following are relevant for the applicant, this information is kept strictly confidential but is required for our statistical purposes. Please tick if applicable:

Family Situation Single Parent Family Unemployed Parents Not living with Parents

Family Background Government Dependant Low Social Skills

Geographic Low Socio Economic Area Economic Hardship

Household Income Below $45k Between $45-80k Over $80k

School Decile Decile Rating 1-2 Decile Rating 3-4 Decile Rating 4-6 Decile Rating above 6

School Attendance Attending school Not Attending School Excluded/Expelled Alternative Ed

Criminal Offending Previous offending Current offending Police referred CYFs referred

Family Active Offending Parent Offending Sibling Offending Close Relative Offending Associates Offending

MarketingHow did the client / student hear about Life Skills (Tick applicable and outline information below)

Friend Family NZ Police Youth Organisation Web Site

Facebook Twitter Flyer Magazine Other

Please outline how you heard about Life Skills

WHY BLUE LIGHT? PLEASE DETAIL WHY YOU WOULD LIKE TO ATTEND A BLUE LIGHT SKILLS COURSE

REFERRER SIGNATURE DATE PRINT NAME

NEW ZEALAND BLUE LIGHT VENTURES CONTACT DETAILS

Return the completed Application by fax, post or email to:

Contact: New Zealand Blue Light VenturesPostal address: PO Box 102 199, North Shore, Auckland 0745Phone: (09) 475 9301Fax: 0800 003331Email: camps@bluelight.co.nz

OFFICE USE ONLY

Date Received: Application Complete: y / n

Entered On File: Applicant: Referrer notified: y / n

Short Listed For Course: Red Flag Review: y / n

Combined Blue Light / NZDF YDU Participant Consent Form Page 5

MeDical HistoRYThis form is to be completed by Parent or Guardian or in their absence the referrer with suitable knowledge of the young person. All information completed on this form will be held in high confidence and is requested for the safety of the young person and others attending the course.

1. peRsonal Details:

First name Last name

Male Female Date of birth Referrer

/ /

Street number and name Suburb Town/City

Home phone Mobile

Email

Age at start of course: Years. Months. Ethnicity(s):

2. next of Kin: (for emergency contact)

First name Last name

Relationship:

Contact address for Next of Kin (for duration of course):

Home phone Mobile

Email

3. MeDical HistoRY, DietaRY ReQUiReMents anD leaRninG aBilitY:a. MeDical:

Name of family doctor, (or the doctor to be contacted in the event of a problem):

Doctor’s telephone No:

Doctor’s surgery address:

Does the applicant have any disease/sickness/injury/allergies/illness/disorder? Yes NoIf YES Explain

Is the applicant recovering from any disease/sickness/injury/operation/illness/disorder? Yes NoIf YES Explain

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Combined Blue Light / NZDF YDU Participant Consent Form Page 6

Are you currently receiving any medical treatment? Yes NoIf YES Explain

Are you taking any medication? Yes NoIf YES Explain

Have you had a reaction to any medical drugs used? Yes NoIf YES Explain

To your knowledge, has the young person ever engaged in aggressive,

self-harmful or suicidal behaviour? Yes NoIf YES Explain type of harm and directed at whom

a. DietaRY: Please state any special dietary requirements (state exact requirements, attach further information if required):

B. leaRninG: Do you have a learning disability? Yes NoIf YES Explain

c. paRent / GUaRDian DeclaRation:

I (full name) declare that the medical information provided above, to the best of my knowledge, is accurate and true and consent to my son / daughter / ward, participating in the course detailed above, which may include general hazards when participating in any of the following activities, mentioned below. A safety management plan can be provided upon request.

Waterborne activities Travel in military vehicles Team sports / Physical training Challenge High Ropes Bushcraft DrillGeneral Trust Activities Confidence Course

I consent to my son / daughter / ward being treated by Blue Light Staff if required. I also consent to Blue Light Staff providing initial assessment during activities and on consultation, commence appropriate treatment as necessary.

Date: Signature:

D. DeclaRation BY stUDent:

I (full name) declare that the medical information provided above, to the best of my knowledge, is accurate and true.

I also consent to Blue Light Staff providing initial assessment during activities and on consultation, commence appropriate treatment as necessary.

Date: Signature:

Combined Blue Light / NZDF YDU Participant Consent Form Page 7

paRticipant consent

The undersigned parties further agree, acknowledge and consent:

• I,(Printfullname) am a proposed participant in a New Zealand Defence Force Youth Life Skills programme.

• NewZealandBlueLightVenturesInchasadvisedmeoftheparticularhazardswhichexistandthesituationswhich could arise where people may not be safe, or harm or serious accident may occur to myself or any other person, which may result in damage to personal belongings, equipment or clothing, injury or death.

• IacknowledgethatIwillbeexposedtosuchhazardsandinsuchsituationswhenpartakingintheYouthLifeSkills Programme.

• IauthorisetheobtainingofmedicalassistanceifintheopinionofNZDFpersonnelsuchactionisnecessary.Costs for medical attention may be forwarded to the referrer/parent to reimburse.

• IconfirmthatIhaveno/fullydisclosedmedicalhistoryorcondition/s,whichcouldactasanimpedimenttomepartaking in this programme.

• Iherebyirrevocablyreleasefromliability,indemnifyandholdharmlessNZDF,BlueLightandNZPolice,itsemployees, consultants, contractors or representatives from all or any liability arising out of any act or omission of NZDF, Blue Light, NZ Police, its employees, consultants, contractors or representatives, which act or omission may result in any damage to property, financial loss, personal injury or death to myself. Further l forgo and waive any right to take any legal action or make any claim of any nature against NZDF, Blue light, NZ Police, its employees, consultants, contractors or representatives, arising from or in connection with the provision of the Services or my participation therein.

• IacknowledgethatduringthetrainingperiodIwillbehandlingpropertybelongingtotheNZDF,BlueLight,NZPolice, and may encounter ammunition and pyrotechnics of all descriptions. I further acknowledge that in the interests of safety, alcohol and illegal drugs are strictly forbidden at all times immediately before or during the course. Accordingly I irrevocably consent to searches of myself, my clothing and my possessions at any time upon entering, and leaving the course, and at any time during training. I understand that I will be searched by someone of the same gender as myself. I understand that I am subject to Regulation 32 of the Defence Regulations 1990 and that my person, my clothing and possessions may be searched by reasonable force if need be. Refer to: http://www.legislation.govt.nz/regulation/public/1990/0078/latest/DLM137452.html#DLM137452.

• IunderstandthatduringmytrainingperiodwiththeNZDFIamsubjecttoDefenceRegulations1990(ptIII)andfailing to adhere to the regulations is punishable on summary conviction to a fine not exceeding $1000 and up to 3 months imprisonment. Refer to: http://www.legislation.govt.nz/regulation/public/1990/0078/latest/DLM136573.html SAVINGS

• NothinginthisCodeofConductAgreementandParticipantConsentinanywayrestrictsorlimitstheexistingor normal protocols or rules of New Zealand Blue Light Ventures Inc, NZ Police, NZDF or the provisions of the Education Act 1989 and all participants are to comply with such protocols and rules and remain subject to the Education Act 1989 at all times.

Combined Blue Light / NZDF YDU Participant Consent Form Page 8

• NothinginthisCodeofConductAgreementandParticipatingConsentinanywayrestrictsorlimitsthepowersof the Defence Force Personnel under the Defence Act 1990 and the Defence Regulations 1990.

• FailuretocomplywithanyoftheaboveconditionsoranyaspectsoftheabovemayresultinremovalfromtheProgramme. Any participants so removed and dismissed will be required to return to their home address at there own expense.

Participant Name

Signature

Date:

Witness Name

Signature

Date:

Parent/Guardian Name (only if Participant under 18)

Signature (only if Participant under 18)

Date: