Early Childhood Excursion Consent Form

Fields marked with an * are required.

As a Parent/Guardian of *

First

Last

Enter Child's First Name and Last Name

in Class

I *

First

Last

Enter Parent/Guardian First Name and Last Name

Email *

Multiple Choice *

give my consent
do not give my consent

for him/her to participate in our excursion to

on

I agree to delegate my authority to the Staff and Instructors involved. The school contact person will be

Class Teacher Email ID *

I authorise Teachers and Instructors to take appropriate action necessary to ensure the safety, well-being and successful conduct of the students as a group, or individually at this excursion and related activities. If any student is unable or refuses to comply with requests, the Teacher may ask parents to come and take the student home.
I also authorise the Teachers and Instructors to obtain medical assistance which they deem necessary should an accident occur, and agree to pay all medical expenses incurred on behalf of the above student.
I submit the attached medical information about the above student and include details of limitations which he/she has for the activity concerned.
I further authorise qualified practitioners to administer anaesthetic if such an eventuality arises.

Emergency Contact for Excursion Day *

First

Last

Enter First Name and Last Name

Contact Number

MEDICAL INFORMATION

Heart Problem

Yes
No

Details, if any *

Respiratory Problem

Yes
No

Details, if any *

Allergies

Yes
No

Details, if any *

Travel Sickness

Yes
No

Details, if any *

Blood Pressure

Yes
No

Details, if any *

Phobias

Yes
No

Details, if any *

Operations

Yes
No

Details, if any *

Recent Illness

Yes
No

Details, if any *

Drug Reaction (e.g. Penicillin Allergy)

Yes
No

Details, if any *

Other Information

Yes
No

Details, if any *

Are you a driver for the excursion

Yes
No

TRANSPORT INFORMATION (if you are a driver for the excursion please ensure the Office has the following details)

Driver Name *

First

Last

Enter First Name and Last Name

Amount to Pay

Minimum Price: $10.00

Payment *

Card

Name on Card

Choose One

Parent
Guardian

Signature *

Clear Signature

Date *