Cnr of University Drive and

Sturt Road
Bedford Park SA 5042

P: +61 8201 XXXX

M: +61 481 200 785
F: +61 8201 XXXX
Consent Form ford0067@flinders.edu.au

As a Parent / Guardian of : flinders.edu.au

STUDENT’S NAME
I:

YOUR NAME
Give my consent for him / her to participate in:

NAME OF ACTIVITY Aquatics – Outdoor Education

At:

LOCATION Port Noarlunga Aquatics

On:

4th June 2019, 9:30 am to 2:00 pm

Agreement

• I agree to delegate my authority to supervising teachers/instructors/students. Such supervisors

may take whatever disciplinary action they deem necessary to ensure safety, well-being and
successful conduct of the students as a group and individually.
• In the event of an accident or illness and contact with me being impracticable or impossible, I
authorise the students in charge to arrange whatever medical or surgical treatment a registered
medical practitioner considers necessary. I will pay all medical and dental expenses incurred on
behalf of my child.
• I have also submitted health care information, including details of any relevant medical or
physical limitations my child has. I also consent to the named doctor or medical specialist being
contacted in an emergency.
• The information given is accurate to the best of my knowledge.

☐ I indicate to not have my child photographed and/or filmed during the event.

Emergency Contacts

Parent / Guardian

NAME
ADDRESS

MOBILE WORK ALTERNATIVE

Family Doctor or Medical Clinic

NAME TELEPHONE
Medical Specialist (if relevant)

NAME TELEPHONE
 Cnr of University Drive and
Sturt Road
Bedford Park SA 5042

P: +61 8201 XXXX

M: +61 481 200 785
F: +61 8201 XXXX
MEDICAL INFORMATION ford0067@flinders.edu.au

Information contained in this section is necessary to ensure that the student’s medical conditions are flinders.edu.au
properly managed, however, no student with special needs will be excluded unless on medical advice.

DOES YOUR CHILD HAVE ANY OF THE MARK ☐ IN THE FURTHER INFORMATION OR SPECIAL INSTRUCTIONS.
FOLLOWING CONDITIONS? BOX IF MEDICATION REQUIRED, SEND WITH STUDENT
CONVULSIONS / SEIZURES YES ☐ NO ☐
( e.g. Epilepsy )
ASTHMA OR OTHER CHEST PROBLEMS YES ☐ NO ☐

ALLERGIES YES ☐ NO ☐
( e.g. bee sting )
DIABETES YES ☐ NO ☐

VISION or HEARING PROBLEMS YES ☐ NO ☐

( glasses or hearing aid )
EAR DISORDER YES ☐ NO ☐
( drainage tubes )
DERMATITIS YES ☐ NO ☐
( e.g. relevant skin conditions )
OTHER RELEVENT CONDITIONS YES ☐ NO ☐
( Autism spectrum disorder )
MEDICATION YES ☐ NO ☐
( e.g. an current medication )
*Any health care information given will not prevent your child from participating unless further medical advice warrants
exclusion. The health care information you supply to the University will be treated confidentially. Such information is
sought in order to protect and assist the student so the activity may be safe and enjoyable. Please contact the University if
you wish to discuss any student health care problems.

As a Parent / Guardian of this student, I give my consent for him / her to participate and agree to the
delegation of authority to the staff and / or instructors and / or students involved.

I have completed the medical information and include details of limitations which my child has for
the activities undertaken. This information is confidential and will only be made available to staff,
instructors and students on a need to know basis.

Signed Date