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Lunch in Schools
Ilminster has been selected to have Lunch in Schools.
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* Indicates required question
I would like my child to receive Lunch in Schools
*
Yes
No
Maybe
A suggestion I have for the menu for Lunch in Schools is:
Your answer
My child has a food allergy.
Yes
No
Clear selection
Student's name (first and last)
*
Your answer
Is your child:
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Female
Male
My childs centre class is room:
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Choose
Rm 1
Rm 2
Rm 3
Rm 4
Rm 5
Rm 6
Rm 7
Rm 8
Rm 9
Rm 11
Rm 12
Rm 13
Rm 17
My child is in Matauranga:
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Choose
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
Year:
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Year 7
Year 8
Students address:
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Your answer
Parent / Caregivers name
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Your answer
Parent / Caregivers contact phone number:
*
Your answer
Parent / Caregivers email:
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Your answer
SWIMMING CONSENT
- For activities where being able to swim is essential. Consent does not remove the need for group leaders to ascertain for themselves the level of the student’s swimming ability. Please click - Yes, No, or Unsure to indicate level of competency for each tasks specified below.
Is your child able to swim 50 metres?
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Yes
No
Unsure
Is your child water confident in a pool?
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Yes
No
Unsure
Is your child confident in deep water?
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Yes
No
Unsure
Is your child able to tread water?
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Yes
No
Unsure
Is your child able to survival float?
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Yes
No
Unsure
Is your child confident in the sea or in open water?
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Yes
No
Unsure
Is your child safety conscious in and around water?
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Yes
No
Unsure
MEDICAL CONSENT:
Please select 'Yes' for all the statements to which you give permission for. Select 'No' if you do not give permission.
In an emergency I give consent that Ilminster Intermediate may act on my behalf.
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Yes
No
Ilminster Intermediate may administer pain relief if deemed necessary.
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Yes
No
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.
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Yes
No
I will inform Ilminster Intermediate school of any changes regarding information on this form - medical or other.
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Yes
No
In the case of an emergency - I agree to my child receiving any emergency medical, dental, or surgical treatment, including anaesthetic or blood transfusion, as considered by the medical authorities present.
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Yes
No
Any medical costs not covered by ACC or a community service card will be paid by me.
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Yes
No
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, he/she will be sent home at my expense.
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Yes
No
PARENTAL CONSENT:
Please select 'Yes' to statements to which you agree. Select 'No' to statements with which you do not agree (if any).
I agree to my child taking part in EOTC events. I acknowledge the need for them to behave responsibly.
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Yes
No
I understand that there are risks associated with involvement in Ilminster Intermediate school’s EOTC events and that these risks cannot be completely eliminated.
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Yes
No
I understand Ilminster Intermediate school will identify any foreseeable risks or hazards and implement correct management procedures to eliminate or minimise those risks.
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Yes
No
I understand that my child will be involved in the development of safety procedures. I will do my best to ensure that my child follows these procedures.
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Yes
No
In order to gain a better understanding of the risks involved - I understand I am able to ask questions about the activities my child will be involved in. I recognise that participation in such activities is voluntary and not mandatory. My child and I both understand that they may withdraw from any activity if they feel at risk. This must be done in consultation with the person in charge.
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Yes
No
I understand that Ilminster Intermediate school does not accept responsibility for loss or damage to personal property (either my child’s property or damage to other’s property caused by my child) and that it is my responsibility to check my own insurance policy.
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Yes
No
STUDENT CONTRACT:
To be read and completed by all participating students or their caregiver on their behalf. NOTE: This section of the form must be completed with explanation and guidance from the parent / caregiver.
I understand that any EOTC event at Ilminster Intermediate is an opportunity for me to learn, practise skills and gain attitudes and values in an environment outside the classroom.
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Yes
No
I understand that this requires me to take responsibility for my behaviour.
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Yes
No
Behaviour expectations:
I agree to do the following:
-Demonstrate PB4L at all times.
-Follow the rules and instructions of staff and other supervisors at any event.
-Take part in all activities within challenge-by-choice options
-Look after myself and my personal belongings
-Declare medical conditions that could affect participation in the event
-Accept the rules set by the school for any event, even if they are different from what is accepted at home.
I have read the behaviour expectations above and agree to follow these on all EOTC that I may be involved with.
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Yes
No
I understand that my parents/caregivers will be contacted and I may be sent home at their expense if: my actions are considered unacceptable by staff, I break the school illegal substances policy or if my actions put myself or others in any danger.
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Yes
No
This section has been completed by
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Student with parent/caregiver
Parent/Caregiver
PARENT / CAREGIVER AUTHORISATION (Electronic signature).
AUTHORISATION: By selecting 'Yes' below I confirm that the information in this form is true and that I grant permission for points specified. By selecting 'Yes' I am, providing my signature as authorisation to this form:
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Yes
No
DATE:
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MM
/
DD
/
YYYY
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