Activity Consent Form

ACTIVITY DETAILS
Activity / ICYS Christmas Holiday Activities- December 2017
Date/s of Activity / Number each activity you wish to attend in preference order: (1=first choice)
___ Wed 13th Dec: Movies/Shops ___ Thurs 14th Dec: Decorations & Treats
___ Tues 19th Dec: XmasLights Tour ___ Thurs 21stDec: Christmas Lunch
PARTICIPANT PERSONAL DETAILS
Name
Address
Home Phone / Mobile Phone
DOB / School
Gender / ☐ Male / ☐ Female
Cultural Identity / ☐Aboriginal / ☐ Torres Strait Islander / ☐Anglo Australian / ☐Other
______
Country of Birth / Interpreting Service Required/Requested
Language/s and dialect spoken (for interpreting purposes) / ☐ Yes / ☐ No
EMERGENCY CONTACT DETAILS
Contact #1
Name
Relationship to participant / Interpreting Service Required/Requested
Language/s and dialect spoken (for interpreting purposes) / ☐ Yes / ☐ No
Phone Number (1) / Phone Number (2)
Contact #2
Name
Relationship to participant / Interpreting Service Required/Requested
Language/s and dialect spoken (for interpreting purposes) / ☐ Yes / ☐ No
Phone Number (1) / Phone Number (2)
MEDICAL INFORMATION
Medicare number / N/A
Private Health Fund details / N/A
Doctor’s Name / N/A
Doctor’s Contact Details / N/A
Does the participant: / YES / NO / IF YES, PLEASE PROVIDE DETAILS
Suffer from a medical condition / ☐ / ☐ /
Have any drug allergies (e.g. Penicillin, Morphine etc.) / ☐ / ☐ /
Have any other allergies / ☐ / ☐ /
Have any special dietary requirements / ☐ / ☐ /
Have a disability/learning difficulty / ☐ / ☐ /
Have any fears/phobias / ☐ / ☐ /
When was the participant’s last Tetanus Toxin Injection / ☐ Within last 2 years / ☐ Within last 10 years / ☐ More than 10 years ago / ☐ Never
If the participant is currently taking any medication, please list the name of the medication, the dosage and the frequency of use
Please note that it is encouraged that all medication be on schedule for the day, ICYS are not permitted to administer medication this includes any panadol/aspirin that may be required on the day. Please consider this when giving approval for attendance.
GENERAL INFORMATION
How well can the participant swim? / ☐ EXCELLENT / ☐ GOOD / ☐ OK / ☐ POOR
Is there any current Child Safety intervention with the participant? / ☐ YES / ☐ NO
Is the participant currently in the care of Child Safety? / ☐ YES / ☐ NO
Is there anyone who is NOT allowed access to the participant / ☐ YES (Please provide details) / ☐ NO
Do you give consent for the participant to be transported by ICYS staff, either in ICYS vehicles or travelling on foot under supervision? / ☐ YES / ☐ NO
Do you allow ICYS staff to take photographs of the participant, which may be used in: / - / -
ICYS newsletters and other promotional material / ☐ YES / ☐ NO
ICYS website / ☐ YES / ☐ NO
ICYS reports / ☐ YES / ☐ NO
School newsletters / ☐ YES / ☐ NO

I consent to participating in the Activity run byICYS Ipswich Community Youth Service. I understand that:

  • The nature of activity-based programs, such as this, involves risks
  • Certain risks are involved with physical activities which may include loss or damage to personal property, injury or fatality
  • While staff make every reasonable effort to minimise risks, not all dangers associated with activities can be foreseen, and I accept that staff cannot guarantee safety where risks are beyond their control
  • In the event of injury to the participant ICYS staff shall administer First Aid and if required, arrange further medical assistance (with any costs to be paid by the parent/carer)
  • ICYS staff undertake to use the utmost care in ensuring each participant has a safe environment to meet personal challenge
  • Appropriate information will be provided to participants before they participate in any activity and that they may choose their own level of participation
  • If the participant breaks certain program guidelines or instructions, I may be required to collect them from the activity.

PARTICIPANT or PARENT/CARER CONSENT
Name
Signature
Date

** Please return this form to: or in person at any ICYS office **

Page 1 of 3

ICYS Activity Consent Form v2.docx