This agreement is about attending an event with Maccabi Victoria All Abilities
This form is also about howMaccabi Victoria All Abilities uses images
Please note:For individuals to participate at the event, this form must be returned.
OPEN DAY: All Abilities Training Session with Damian Ryan
Event: Monday31stMarch 2014
You will be attending the Maccabi Victoria All Abilities training session on Monday 31st of March, 2014 from 6.30-7.45pm at OrrongRomanis Stadium (2 Molesworth Street, Prahran VIC 3181).
At this event you will be participating in a training clinic run by Damian Ryan, with Kathryn Hay (coach) and assistant coaches.
I will advise Maccabi Victoria of medical condition concerning that would place them in danger of any medical injury as a result of participating in the named event.
I agree to release Maccabi Victoria from all claims arising from this Excursion. It is at the discretion of Maccabi Victoria that they make modifications to a project in the event that either party to this agreement is dissatisfied with its outcomes. In the event that there are changes to this event a new Consent agreement will be presented to you.
Name:______
What does this agreement mean?
- You agree to attend the Event and follow the directions of the Maccabi Victoria staff
- Whether you will give permission for your imageto be used by Maccabi Victoria only for:
Promotion
Publicity
Information
Activities you will do withMaccabi Victoria:
Play basketball
Do you agree to your image or likeness being used?
PhotographsOn LineFilm
YES, onlyMaccabi VictoriaCAN use my image or likeness.
NO, MaccabiVictoria CANNOT use my image, or likeness.
?Do you understand what this Consent Form means?
YES, I understand.
NO, I do NOT understand.
Do you agree to the Consent Form?
YES, I agree.
NO, I do NOT agree.
Your Name:
Address:
Suburb:State:Postcode:
Home Phone:Mobile:
email:
Your Signature:
Who has helped you understand the Consent Form?
has helped me to understand this form.
Acknowledgment bythird party –
the person helping with this form
I have explained the purpose of this form as required and am satisfied that the person participating in this activity or project, who signs this form:
1.understands the form and the obligations arising from signing the form;
2.has provided their consent freely; and
3.is aware of the details of the event and that Maccabi Victoriamay create in a permanent form a representation of their image, and likenessand may not be removed once consent has been given.
I am aware that Maccabi Victoria will rely on my acknowledgement in the event that I have explained the terms of this agreement to the person signing this form to the best of my ability and that the person understood the terms of the agreement to the best of his or her ability. I understand the form and the event brief.
Name:
Signature:
Relationship to person signing the form:
Date:
To be completed by Clients Financial Guardian
I authorise any member of Maccabi Victoria staff, volunteer or representative accompanying Clients on events to obtain any hospital, medical or associated assistance, and for any treatment or procedure thought necessary in the event of illness or accident. I agree to pay or reimburse any expenses so incurred.
Please list a contact person and telephone number in the event of an emergency on the day of this event.
Contact Person: ......
Telephone Number: ......
Parent/Guardian Name: ......
Signature: ......
Date: ......
Medical Information:
Please complete the following details:
Medical conditions: (give details of how treated and managed and any conditions requiring special attention. E.g epilepsy warning signs & management, asthma and treatment plan, diabetes and treatment plan)......
Allergies: (give details of how managed and avoided): ......
Illness to which person is prone: (Give details of recommended treatment): ……………………………………........
Relevant health information (Including emergency or special health procedures)
......
Please specify any assistance required or equipment used and what (if any) personal support is required to assist your child in being involved with sporting activities?
......
Medicare Number: ......
Private Health Fund: ......
Ambulance Cover and Number: ......
Health Fund Membership Number: ......
Family Doctor Name: ......
Doctor Telephone Number: ......
Client’s Mobile Number: ......