Horowhenua College Hazardous Activity Consent Form

The purpose of this form is two fold. One is so that the parents are aware that their child is participating in an activity that has a certain degree of high risk and secondly that some of these activities are not covered under the Uni-Care Insurance Policy.

Name of student Country

Mark the activity for which permission is given

Group A – These are covered by the Uni-care insurance policy as long as they are done with a licenced tour operator

[ ] Jet boating [ ] Parapenting (tandem parachute from hill with instructor)

[ ] Bungee jumping [ ] Sky diving (tandem parachute jump from plane

with a instructor)

[ ] Kayaking [ ] Para Sailing (parachute towed behind boat)

Group B is not covered by the insurance policy

[ ] Private air plane ride [ ] Mountain climbing (with climbing equipment)

[ ] Hot air ballooning [ ] White water rafting (in fast flowing river rapids)

[ ] Caving/.potholing [ ] Black water rafting (in underground caves)

[ ] Scuba diving [ ] Abseiling (descending a cliff by harness)

[ ] Hunting [ ] Canyoning (abseiling and river crossing)

[ ] Hang gliding [ ] River surfing (riding river rapids on body boards)

[ ] Zorbing (rolling down a slope in a ball) [ ] Swoop swings (40 meter drop in harness)

Other please specify

Group C (Outdoor Education Programme – Year 11, 12 and 13 should your son/daughter chose this subject). The course may include:

[ ] Track cycling/road biking [ ] Top rope climbing

[ ] Bush craft skills [ ] Acquatic confidence/rolling a kayak

[ ] Mountain biking [ ] High ropes course

[ ] Sea kayaking [ ] Optional ski trip to Whakapapa Ski Field

[ ] Bush craft/tramping

I am aware that in the event of death or injury to my son/daughter arising from participating in any of the above stated activities which are or could be outside the scope of the insurance policy, I accept all additional financial responsibilities which may be incurred.

In the event that my son/daughter takes part in any of the above listed activities for which my permission has not been obtained or has been forbidden then

a) I will not hold Horowhenua College responsible, and

b)  I realise that any financial or legal outcome will be my responsibility.

.

Signature Print full name

[ ] Father [ ] Legal guardian

Date

______

Signature Print full name

[ ]Mother [ ] Legal guardian

Date

Both parents sign

11/2011