Waikato Holiday Programme 2017

1. Child Young Person Details Form 2. Consent/Agreement Form

Please complete one per year

Name of Holiday Programme:
1. Child/Young Person Details
First Name: / Surname:
Gender: / Date of Birth: / Ethnicity:
Diagnosis:
(List all) / Year of Diagnosis:
Parent/Caregiver Details
Name: / Relationship to child:
Home address:
Suburb: / City: / Postcode:
Phone: / Mobile:
Email address:
Postal address (if different) / &/or Child’s second address (if required):
Suburb: / City: / Postcode:
How did you hear about the Holiday Programme?
Emergency Contact 1
Name: / Phone:
Relationship to child/young person:
Emergency Contact 2
Name: / Phone:
Relationship to child/young person:
Authorised people to pick up child/young person (other than stated above)
Name: / Phone:
Relationship to child/young person:
2. Holiday Programme Consent/Agreement (Terms & Conditions)
  1. Interaction between your Child/Young person and Holiday Programme Employee/Volunteer
During the Holiday Programme, the Holiday Programme employee/volunteer may sometimes need to touch your child/young person. This will always be done appropriately and in full view of others. If you have any concerns, or your child/young person has particular needs in this regard, please discuss them with the Holiday Programme employee/volunteer before the programme. To allow such touching, indicate your opinion:
I/We agree my/our child may be touched appropriately by the Holiday Programme employee/volunteer, if required.
Yes / No
  1. Transport
2.1Transport to and from the Holiday Programme
During the Holiday Programme, it is the parent/caregiver’s responsibility to transport the child/young person to and from the Programme. The drop off time must be no earlier than 9am and the pickup time must be no later than 3pm.
I/we agree that it is my responsibility to provide transport to and from the programme which must be within the Holiday Programme operating hours (9am – 3pm).
Yes / No
2.2 Transport during the Holiday Programme
Autism New Zealand ensures that transport during the Holiday Programme is provided in a private vehicle with a current warrant of fitness and registration. The driver of the vehicle will also have full, clean New Zealand Driver’s License.
I/we agree to Autism New Zealand providing transport for my child/young person during the Holiday Programme.
Yes / No
2.3 Child Restraint Law
The Child Restraint Law states that all children up until their 7th birthday or person under 148cm must be in an approved child restraint or booster seat. If applicable to your child/young person, it is the parent/caregiver’s responsibility to provide the necessary equipment.
I/we agree to provide the necessary equipment (i.e. child restraint or booster seat) to meet requirements of the Child Restraint Law.
Yes / No
Holiday Programme Consent/Agreement, continued
  1. Illness/Emergency/Behaviour
3.1 Illness
If a child/young person is ill or has an infectious condition e.g. mumps, conjunctivitis, head lice, diarrhoea, cold, flu, and/or vomiting (within the last 48 hours), or is in need of medical attention, the child/young person must be kept at home for the health and safety of the other participants on the Programme.
If the child/young person becomes ill during the course of the day, a Holiday Programme employee/volunteer will contact the parent/caregiver or emergency contact to collect the child/young person immediately from the Programme.
I/we agree to keep my child/young person at home if they are ill and understand it is my responsibility to collect them if they become ill during the Programme.
Yes / No
3.2 Emergency
Physical and emotional safety is very important and all steps will be taken to avoid unnecessary stress and danger to the children/young people and Holiday Programme employees/volunteers. All children/young people will receive the level of supervision necessary to ensure their safety and the safety of others.
If a minor accident occurs on the programme requiring minor medical attention, the parent/caregiver or emergency contact will be contacted immediately. If there is an emergency and the child/young person needs to be taken to hospital, the child/young person will be supported by a Holiday Programme employee/volunteer until the parent/caregiver or emergency contact arrives.
Your child/young person’s medical information will be given to the medical professionals (if required) and a report completed on behalf of a Holiday Programme employee/volunteer.
I/we agree for the Holiday Programme employee/volunteer to provide minor medical assistance for my child/young person
Yes / No
I/we agree for the Holiday Programme employee/volunteer to seek urgent medical assistance for my child/young person if an emergency contact cannot be reached.
Yes / No
I/we agree my child/young person’s personal medical details be given to a medical professional in an emergency situation.
Yes / No
Holiday Programme Consent/Agreement, continued
3.3 Behaviour
Autism New Zealand retains the right to remove your child/young person if they are exhibiting disruptive behaviour that is a health and safety risk (to themselves or others). A Holiday Programme employee/volunteer will contact the parent/caregiver to collect the child/young person immediately from the Programme.
I/we agree it is my responsibility to collect my child/young person if they are exhibiting disruptive behaviour that is a health and safety risk to themselves or others on the Holiday Programme.
Yes / No
I/we agree Autism New Zealand shall not be liable for any damages or costs incurred by my child/young person’s accidents or illnesses during the programme.
Yes / No
4Use of videos for training and evaluation
Autism New Zealand would appreciate being able to use some photos/videos of participants taken during the Holiday Programme for evaluation and training of the Holiday Programme employees and volunteers. To allow this sharing, please indicate your opinion:
I/we agree to the use of videos for training and/or evaluation of Holiday Programme employees and volunteers.
Yes / No
5Use of videos/photos for reporting, publicity and fundraising
From time to time, Autism New Zealand uses video clips and photos of Holiday Programme participants for reporting, publicity and fundraising.
Examples include publishing photos in the Annual Report, in brochures promoting programmes, and in funding applications. Video clips or stills may be posted on our website or Facebook pages for the same purposes.
Would you consider giving permission for such use of some image/video of you and/or your child participating in this Programme? We would contact you before posting/publishing any images to gain your permission for use of each specific photo or video. Please indicate your opinion in the following:
I/we agree to the possibility of posting/publication of images/video clips of myself and/or my child/young person taken during the Holiday Programme in Autism New Zealand’s reporting, publicity or fundraising material.
Yes / No
Holiday Programme Consent/Agreement, continued
6Confidentiality
During the course of the Holiday Programme, your child/young person will/may be assigned a Holiday Programme employee/volunteer. To ensure the health, safety and wellbeing of the child/young person, the Holiday Programme employee/volunteer will require access to your child/young person’s profile outlining information such as likes, dislikes, medications and behaviours etc.
All information relating to the child/young person involved in the Holiday Programme will be kept confidential during and following the Programme.
I/we agree to give access of my child/young person’s profile details to the Holiday Programme employee/volunteer.
Yes / No
7Custody Access
Yes / No
If yes, please provide relevant supporting documents where necessary.
8Consent of Child/Young Person’s Parent/Caregiver
I/We have read and understood all of the above parts of the Participation Agreement and agree to all the above consents.
Name:
Signed: / Date:
Disclaimer: By typing your full name, you are signing this Agreement/Consent Form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement/Consent Form. By typing your full name, you consent to be legally bound by this Agreement's terms and conditions.
Note – If any of the information you have provided on the child/young person details or consent/agreement form changes it is your responsibility to let the holiday programme coordinator know.
Autism New Zealand Membership (automatic)
By signing up to this programme you agree to be added to the Autism New Zealand Membership.
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