King’s Adventure Challenge

A journey leading to more than just adventure

Parental Consent, Emergency Contacts and Risk Disclosure

Form Class:
House:
Details of event: / King’s College Adventure Challenge in conjunction with Adventure Specialties
Start date: / King’s College Triangle Tuesday 8:30 a.m.
As per King’s Calendar
Finish date: / King’s College Triangle Friday 3:00 p.m.
As per King’s Calendar
PARTICIPANT INFORMATION FORM
Please complete these details:
Name Student
Address
Mobile
Telephone (Home) / Parent Mobile
Age
Form Class / House
Family Doctor Name / Telephone
Doctor’s Address
Medic Alert number (if applicable)
EMERGENCY CONTACT DETAILS (please provide at least 2 sets of contact details)
Contact 1: Emergency Contact / Relationship:
Name: / Relationship:
Address:
Evening Phone:
Day Phone: / Evening Phone:
Mobile:
Contact 2: Alternative contact / Relationship:
Name: / Relationship:
Address:
Evening Phone:
Day Phone: / Evening Phone:
Mobile:
To be read and signed by adult assistant or parent/caregiver of child participant.
Parental Consent
I agree to my son/daughter taking part in anAdventure Specialties, New Zealand Sailing Trust & King’s College Adventure Challenge programme. I agree to his participation in the activities described. I acknowledge the need for him to behave responsibly.
I agree that my son’s written evaluation of the journey, group stories, videos or photographs may be used in publications associated with the organizations. Publications may include newsletters, annual reports, websites, Facebook and in the media.
Acknowledgement of Risk
I understand that there are risks associated with any involvement in a school EOTC event and that these risks cannot be completely eliminated. I understand that the NZ Sailing Trust, Adventure Specialties and King’s will identify any foreseeable risks or hazards and implement correct management procedures to eliminate, isolate or minimise those hazards. I understand my son will be briefed with these safety procedures on boarding the vessel, at Ahuroa & withAdventure Specialties. I will do my best to ensure that my son follows these procedures.
River Rafting is an adventure activity with a degree of risk, which increases with the grade of rapids. Your son may be rafting rivers between grade 1 and 3. Participants should be aware that the commercial operator cannot guarantee your safety.
I acknowledge that I am able to ask any questions of the NZ Sailing Trust, Adventure Specialties, or the school about the activities my son/daughter will be involved in to gain a better understanding of the risks involved. I recognise that participation in such activities is voluntary and not mandatory through a ‘challenge by choice’* procedure. My son and I both understand that he may withdraw from an activity if hefeels at risk. This must be done in consultation with the person in charge.
I understand that the NZ Sailing Trust, Adventure Specialties, or King’s does not accept responsibility for loss or damage to personal property and that it is my responsibility to check my own insurance policy.
Name:
Signature:
Date:

*‘challenge by choice’ means the participant chooses their own level of challenge within a supportive peer environment.

KING’S COLLEGEADVENTURE CHALLENGE

“A journey leading to more than just adventure”

The information on this form will, in general, remain confidential to the teachers/instructions in charge of/or assisting with this trip. However, in the interests of the safety of all involved, any life threatening conditions may have to be made known to other students.

Please be assured that your son/daughter’s physical and emotional well-being remains of paramount importance to us at all times.

Son’s Name
Form Class / Does he wear a Medic Alertbracelet – if so what is the number &
where is it worn
1. Please tick if your sonhas any of the following:
Migraine / Epilepsy / Asthma
Diabetes / Travel sickness / Fits of any type
Chronic nose bleeds / Heart condition / Dizzy spells
Colour blindness / Anaphylaxis
Other (Please specify)
As your son will be rooming with other students, please provide information on any relevant issues:
Sleepwalking / Snoring / Sleep Apnoea
2. Is your son currently taking medication? / Yes / No
If YES, please state ailment/s:
Name/s of medication/s:
Dosage and time/s to be taken:
Other Treatment:
3. Has your son had any major injuries (breaks or strains) or illness (glandular fever etc.) / Yes / No
in the last six months that may limit full participation in any activities?
If YES, please give details of the injury/illness.
Please attach any additional information if relevant.
4. Is your son allergic to any of the following?
Yes / No / Please specify and treatment required
Prescription medication
Food
Insect bites/stings
Other allergies
5. When was your /your child’s last tetanus injection?
6. Outline any dietary requirements:
7. Please tick the box if you are happy for your son to be administered antihistamines in the case of any allergies:

8. Please tick the box if you are happy for your son to be administered over the counter medicine:
e.gParacetamol
Ibuprofen
Anti-Sea sickness tablets
Cough medicine

9.To the best of your knowledge,has your son been in contact with any / Yes / No
Contagious or infectious diseases in the last four weeks?
If YES, please give brief details:
10. Is there any information the staff should know to ensure the physical and emotional safety of you/your child? (For example cultural practices; disability; anxiety; about heights/darkness/small spaces; behaviour or emotional problems).
Yes / No
If YES, please state or attach the information.
MEDICAL CONSENT
IF ANYTHING CHANGES BETWEEN COMPLETING THIS FORM AND THE TRIP IT IS ESSENTIAL YOU LET US KNOW.
I certify I am the legal Guardian of (name of student)
Where it is impractical to contact me, I authorise the teacher/instructors in charge of the programme to consent to the child receiving such medical or surgical treatment as may be deemed necessary.
TICK
I agree that if prescribed medication needs to be administered, a designated adult will be assigned to do this.
I will ensure that prescribed medication is clearly labelled, securely fastened and handed to the designated adult with instructions on its administration.
I will inform the school as soon as possible of any changes in the medical or other circumstances between now and the commencement of the event.
I agree to my child/myself receiving any emergency medical, dental, or surgical treatment, including anaesthetic or blood transfusion, as considered necessary by the medical authorities present.
Any medical costs not covered by ACC or a community service card will be paid by me.
If my son is involved in a serious disciplinary problem, including the use of illegal substances and/or alcohol, or actions that threaten the safety of others, s/he will be sent home at my expense.
SWIMMING ABILITYINFORMATION
No / Yes
Are you able to swim 50 metres?
Are you confident in deep water?
Are you able to tread water?
Are you able to survival float?
Participant Signature ______
Parent / Guardian signature ______Date ______