This agreement is about attending an event with Maccabi Victoria All Abilities
This form is also about howMaccabi Victoria All Abilities uses images
Please note:For the Members to participate in this activity this form must be returned.
STRIKE OUT! Tenpin bowling event
Sunday 25th May, 2014
Please tick or highlight which program you will be attending:
☐Program for Jewish individuals with all abilities aged 12-17 years (1pm - 3pm)
☐Program for Jewish individuals with all abilities aged 18 years and older (3.30pm-5.30pm)
I will be attending the program highlighted above, which will include:
- One hour of playing tenpin bowling
- One hour of enjoying afternoon tea with other attendees
I will advise Maccabi Victoria of any concerning medical conditions that would place me in danger of any medical injury as a result of participating in the named event.
I agree to release Maccabi Victoria from all claims arising from this Excursion. It is at the discretion of Maccabi Victoria that they make modifications to a project in the event that either party to this agreement is dissatisfied with its outcomes. In the event that there are changes to this event a new Consent agreement will be presented to you.
Name:______
Activities you will do with Maccabi Victoria:
Meet at AMF Bowling, Moorabbin / Play tenpin bowling / Eat afternoon tea with othersWhat does this agreement mean?
- You agree to attend the Event and follow the directions of the Maccabi Victoria staff
- Your image may be used by the organisation providing this service to you for
Promotion
Publicity
Information / / /
Do you agree to your image or likeness being used?
Photographs / On Line / FilmYES, Maccabi Victoria CAN use my image or likeness.
NO, Maccabi Victoria CANNOT use my image, or likeness.
Do you understand what this Consent Form means?
YES, I understand.
NO, I do NOT understand.
Do you agree to the Consent Form?
YES, I agree.
NO, I do NOT agree.
Your Name:Your Age:
Address:
Suburb:State:Postcode:
Home Phone:Mobile:
email:
Your Signature:Who has helped you understand the Consent Form?
has helped me to understand this form.
Acknowledgment bythird party –the person helping with this form
I have explained the purpose of this form as required and am satisfied that the person participating in this activity or project, who signs this form:
1.understands the form and the obligations arising from signing the form;
2.has provided their consent freely; and
3.is aware of the details of the event and that Maccabi Victoria may created in a permanent form a representation of their image, and likeness may not be removed once consent has been given.
I am aware that Maccabi Victoria will rely on my acknowledgement in the event that I have explained the terms of this agreement to the person signing this form to the best of my ability and that the person understood the terms of the agreement to the best of his or her ability. I understand the form and the event brief.
Name:
Signature:
Relationship to person signing the form:
Date:
To be completed by Clients Financial Guardian
I authorise any member of Maccabi Victoria staff, volunteer or representative accompanying Clients on events to obtain any hospital, medical or associated assistance, and for any treatment or procedure thought necessary in the event of illness or accident. I agree to pay or reimburse any expenses so incurred.
Please list a contact person and telephone number in the event of an emergency on the day of this event.
Parent/Guardian Name: ......
Telephone Number: ......
Signature: ......
Date: ......
Medical Information:
Please complete the following details:
Medical conditions: (give details of how treated and managed and any conditions requiring special attention. E.g epilepsy warning signs & management, asthma and treatment plan, diabetes and treatment plan)......
Allergies: (give details of how managed and avoided): ......
Illness to which person is prone: (Give details of recommended treatment): ……………………………………........
Relevant health information (Including emergency or special health procedures)
......
Please specify any assistance required or equipment used and what (if any) personal support is required to assist your child in being involved with sporting activities?
......
Medicare Number: ......
Private Health Fund: ......
Ambulance Cover and Number: ......
Health Fund Membership Number: ......
Family Doctor Name: ......
Doctor Telephone Number: ......
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