Queechy High School eNewsletter

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Major Excursion Consent and Medical Information Form

• This form is to give permission for your child to attend a camp/excursion; and
• To provide medical information that might be needed in case of emergency.

Excursion Details

Date *

Location(s) *

Brief Description *

Teacher(s) in Charge *

Personal Details

Student Name (First Name and Surname) *

Grade/Class *

Date of Birth *

Home Address *

Emergency Contacts

Emergency Contact 1 Name (First Name and Surname) *

Emergency Contact 1 Relationship *

Emergency Contact 1 Email *

Emergency Contact 1 Phone Number *

Emergency Contact 2 Name (First Name and Surname)

Emergency Contact 2 Relationship

Emergency Contact 2 Email

Emergency Contact 2 Phone Number

Emergency Contact 3 Name (First Name and Surname)

Emergency Contact 3 Relationship

Emergency Contact 3 Email

Emergency Contact 3 Phone Number

Doctor/Medical Practice *

Doctor/Medical Practice Phone Number *

Doctor/Medical Practice Address *

Medicare Number *

Private Health Fund

Private Health Fund Number

Tablets and Medicine

Is your child taking any tablets and/or medicine? *

Yes

If Yes please state name of medication, dosage, etc. and answer the following two questions:

Have you completed an Administration of Medication Authorisation?

Yes

Has your Doctor/Pharmacist/Practice Nurse completed an Administration of Prescribed Medication Authorisation?

Yes

If you have not completed an Administration of Medication Authorisation Form please either download it from our website or collect a form from the school

https://queechyhs.schoolzineplus.com/first-aid-and-medication

Please tick if your child suffers any of the following medical conditions

Please provide further details about your child's medical condition (if applicable)

Please indicate if (and what) your child is allergic to (if applicable)

Consent Form

Medical:
In the event of accident or illness when it is impracticable or impossible to communicate with me, I authorise the teacher(s) in charge or their delegate to:
• consent to such medical or surgical treatment as may be deemed necessary
• administer such first aid as may be judged to be necessary.

Participation:
I consent to my child’s participation in this excursion. I have been fully informed by the school of the arrangements made for the conduct of this excursion. I understand that the excursion includes activities that may involve some risk as set out in the excursion description/attached excursion itinerary and information.
Expenses:
I agree to my child returning home if necessary, in the event of illness or injury, and to pay any expenses involved or to come and collect my child from the excursion.
I acknowledge that during the excursion, acceptable standards of behaviour will be expected of the students.
I understand that my child may be sent home in the event of serious misbehaviour during the excursion. I further understand that in such circumstances I will be informed and that any costs involved will be my responsibility.
I agree to reimburse the school for any wanton damage caused by my child.
I agree to reimburse the school for any hospital, medical or ambulance expenses incurred by the school on behalf of my child.

Overseas travel only:
I understand that overseas travel is subject to a number of potential risks and that following travel being approved, a direction may me made to cancel travel, change the itinerary, or require travellers to return home at the earliest opportunity. This decision will be made on the basis of all information available, not just that which is publicly available.

I understand that travel insurance is not provided for my child by the Department of Education and that there may be costs incurred as a result of any direction noted above. I understand the importance of purchasing my own travel insurance as these costs may be covered by that insurance.

Excursions with a billeting component only:
I understand that billeting is the temporary lodgement of students staying overnight in the homes of volunteer host families. Specific information about billeting arrangements is provided in the attached Excursion Itinerary and Information.
I am aware that host families have been subject to appropriate safety screenings by the teacher (e.g. requirements to have Working With Vulnerable People registration).
I acknowledge that host families may provide accommodation, meals and transport for students, as set out in the Itinerary.
I consent to my child being billeted overnight with a volunteer host family for all or part of the duration of the excursion.

A parent/guardian must notify the school if there is any change to the information provided on this form.

Parent/Guardian First Name *

Parent/Guardian Last Name *

Email *

Signature *

Undo

Clear

Write your signature above the line

Consent for aquatic activities – In addition to this form, specific consent has to be given for any excursion involving aquatic activities. Please read, sign and return the attached consent form.

Personal Information Protection Statement

Personal information will be collected from you for the purpose of obtaining student details and will be used by the school/ college and the department for managing school excursions. Failure to provide this information may result in your child being unable to attend the excursion. Personal information will be used for the primary purpose for which it is collected and may be disclosed to health care and emergency services in the case of an emergency. Personal information will be managed in accordance with the Personal Information Protection Act 2004 and may be accessed by the individual to whom it relates on request to the Principal. You can obtain a copy of the Department of Education’s Personal Information Protection Policy on request to (School Name) or on the Department of Education website at: http://www.tas.gov.au/stds/pip.htm