Permission Form
Name of School: Mildura Youth Centre
Child’s (the Child) Surname: ______
Given Names: ______
Home Address: ______
Parent’s (the Client) Contact Phone Numbers:
______(Home) ______(Work) ______(Mobile)
Preferred Emergency Contact Person: ______
Emergency Contact Phone Numbers:
______(Home) ______(Work) ______(Mobile)
Image Use
Images, tape and film recorded by Wild Side Outdoors staff remain the sole property of Wild Side Outdoors and maybe used for the following purposes:-
- Media reports on Wild Side Outdoors programs and products that maybe broadcast locally, nationally and internationally via the print, television, radio or social media.
- Camp reports that will appear on the Wild Side Outdoors web site and/ or Social media pages.
- Promotional materials for Wild Side Outdoors program and products that maybe be distributed locally, nationally and internationally.
Under no circumstances will images, video or film be used for purposes other than for the reporting of a Wild Side Outdoors activity or program or for the promotion and advertising of Wild Side Outdoors programs and products.
Images, video and film will only be utilised by Wild Side Outdoors if considered appropriate for the purposes for which it was intended and will not be made available to other outside agencies, organizations or businesses.
If any images of students require that the student’s full name be included, Wild Side Outdoors will first seek the permission of the parents of the relevant child.
Equipment Use
Equipment is provided in good working order. Children are expected to show respect for the equipment and use it according to guidelines and instruction given during the activity.
Wild Side Outdoors will accept responsibility for damage or loss incurred whilst the equipment is being used according to such guidelines and instruction.
Statement of Risk
The water and land based activities carried out during the activity will vary in nature however some have an element of adventure and therefore have inherent risks.
Every effort will be made to eliminate or minimise exposure to these risks during the activity however it is essential that participants are properly prepared in accordance with guidelines given.
Disclaimer
The client states that their Child is in sound physical condition and have no injuries or illnesses that may prevent them from participating in a safe and sensible manner. It is a condition of this agreement that the Child is to immediately discontinue participation if they suffer an injury or illness that may prevent them participating in a safe and sensible manner. The Client agrees with Wild Side Outdoors that Their Child will obey and will comply with all rules and directions made or given by Wild Side Outdoors staff in connection with the described activity.
The client agrees to meet any expenses required if their Child is returned to school / home if in the opinion of the teacher in charge their Child has seriously breeched behavioural rules. This may include a staff member’s transport costs (to and from the camp) or the client collecting the Child personally.
If the client’s Child suffers any injury or illness, the client agrees that Wild Side Outdoors and/or the teacher in charge may provide evacuation, first aid and medical treatment at the client’s expense, and the client’s acceptance of these terms and conditions constitutes the client’s consent to such evacuation, first aid and/or medical treatment.
Wild Side Outdoors will not be responsible for any personal loss suffered as a result of participation in the activity. Wild Side Outdoors and associated authorities are indemnified from all liability associated with the activity and released Wild Side Outdoors from any actions that may be instituted against them in relation to the activity.
A Note About This Form
This form has been designed to improve your understanding of the camp and to establish an agreement with you that will enable us to deliver a quality program for your Child.
It provides us with the opportunity to establish an agreement with you that clearly outlines the expectations for both us, as activity providers and you and your Child as clients.
Through this agreement we hope to gain your trust in that we will operate the camp program in a professional manner with the best interests of your Child as the major priority.Parent or Guardian Consent
I ______give permission for my Child ______
to attend the Mildura Youth Centreactivity
at the Kings Billabong Wildlife Reserve on Thursday, April 6, 2017.
I agree that images of my Child may be used as prescribed and that my Child will use equipment only as directed.
I have read the Statement of Risk supplied and understand that every effort will be made to ensure that my Child is able to participate in the camp program in a safe and enjoyable manner. I approve of the transport arrangements and to my Child taking part in the Camp and Activity Program.
Signed: ______Date: ______
Student Agreement
I ______agree to abide by the rules of the camp and to cooperate
with supervising adults. I understand that if I seriously breach the set rules, I will be returned home at my parents/guardians expense.
Signed: ______Date: ______
Water Based Activities (If applicable)
I ______give permission for my Child to participate in water
based activities. I verify that my Child is confident in the water, has basic survival swimming skills and can swim a distance of 30 metres unaided.
Signed: ______Date: ______