Yr9 Exploration Days Weds 19 - Fri 21 Feb 2020
The above event involves risk exposure greater than what would typically be the case at school, such as being on a ferry, going to Mana Island and some shallow water activities at Onehunga Bay, Whitireia Park.  As a result we are seeking further consent from you and are asking you to update the health and contact information held by the school.
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Email *
Caregiver Consent & Emergency Contact Information
Details on this form will remain confidential to school staff, contractors and volunteers associated with supervising activities on this event. It is crucial that you provide us with up to date health and emergency contact information, that is accurate and complete, to allow us to plan appropriately for this and future EOTC events.
Student's Name *
Student's Address *
Student's LA class *
Student's Cellphone Number
Emergency Contact 1 Full Name (i.e. Parents/Caregivers) *
Emergency Contact 1 Phone Numbers (i.e. Parents/Caregivers, cell, work &/or home) *
Emergency Contact 2 Full Name (i.e. Alternative- whanau/close friends etc) *
Emergency Contact 2 Phone Numbers (i.e. Alternative- whanau/close friends etc -cell, work &/or home) *
Parental Consent *
Required
Acknowledgement of Risk *
Tick/Check
I have read the EOTC event information letter previously sent via email and I understand that there are risks associated with involvement in school EOTC events and that these risks cannot be completely eliminated. I understand that the school will identify any foreseeable risks or hazards and implement correct management procedures to eliminate, isolate or minimise those hazards. I understand my child has been involved in the development of safety procedures. I will do my best to ensure that my child will follow these procedures.
I know that I am able to ask any questions of the school about the activities my child 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. My child and I both understand that they may withdraw from an activity if they feel at risk. This must be done in consultation with the person in charge.
I understand that the school does not accept responsibility for loss or damage to personal property and that it is my responsibility to check my own insurance policy.
Health Details and Medical Consent
Please tick if your child has any of the following *
Required
Is your child currently taking any medication?
Clear selection
If YES please state a) Health conditions, b) Name of medications, c) Dosage and time/s to be taken, d) Other treatment. *
Has your child had any major injuries (breaks or strains) or illness (glandular fever etc) in the last six months that may limit full participation in any activities? *
If YES please state the injury/illness. *
Is your child allergic to any of the following? *
Required
Please specify the checked allergy (or Nil if Nil) *
Please outline any dietary requirements *
What pain/flu medication may your child be given if necessary? *
To the best of your knowledge.  Has your child been in contact with any contagious infectious diseases in the last four weeks? *
If YES or Maybe please give brief details (or Nil if No) *
Is there any information the staff should know to ensure the physical and emotional safety of your child? *
If YES or Maybe please state detail (or Nil if No) *
Health Consent
Tick/Check
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 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 child 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.
Water/Aquatic Consent (re waist height water maximum at Onehunga Bay, Whitireia Park) *
Yes
No
Don't Know
Is your child able to swim 50 metres?
Is your child water confident in a pool?
Is your child confident in deep water?
Is your child able to tread water?
Is your child able to survival float?
Is your child confident in the sea or open inland water?
Is your child safety-conscious in and around water?
Name of person completing this form & Date *
Submit
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