Activity Release Form

Join the Movement

To be completed by each participant’s Parent/Guardian

Participant’s details:

Participant’s details
First Name
Surname
D.O.B.
Gender
Please advise us of special conditions or requirements where relevant (medical, phobias, allergies etc.)?
Activity

Parent/Guardian details:

First nameSurname

Mobile

Emergency Contact details in the event of an emergency:

Name Phone number

Relationship

You (as the parent/guardian of participant – listed above):

  • agree that you have voluntarily chosen to for the participant to participate in the activity/ activities listed above (Activity) and understand that it may involve physical activity of a strenuous nature;
  • understand and acknowledge that the Activity is not completely free from risk, there are certain inherent risks (including the risk of injury or death) in all aspects of physical activity which cannot be eliminated and remain integral to the Activity;
  • knowingly assume all of the inherent risks of the Activity;
  • warrant that the participant is in good health and proper physical condition to safely participate in the Activity and that the participant has no known physical or mental conditions that would adversely affect the participant’s ability to safely participate in the Activity;
  • give the department, event staff and the persons leading the Activity permission to seek emergency medical services for the participant becomes ill or injured, and you agree to pay the costs of those services;
  • acknowledge that while participating in the Activity the participant may be filmed (video recorded) or photographed. You give consent to the participant being photographed and their image and voice being recorded, and replayed/ published to other audiences, including being made publicly available on the internet and/or used by the Department of National Parks, Sport and Racing for promotional (including as part of the Join the Movement campaign) and training purposes; and
  • consent to the participant’s email address to be used, in the future, to provide the participant with updates about future events hosted by the Department. You can unsubscribe at any time by notifying the Department in writing.

You, release and discharge the Department and its Representative (meaning an employee, agent, officer, contractor or other authorised representative), from any and all liability for loss, claims, demand, damage, injury or expense, that any of you or the participant suffer as a result of participation in the Activity and or attendance at the event, due to any cause whatsoever, including negligence.

I am the parent/guardian of the participant listed above and have read, understood and agree to the above terms and conditions:

Signature of participant or parent/guardian: Date:

Activity Release Form

Join The Movement

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