Parental Consent, Emergency Contacts and Risk Disclosure

School/group: Class 3A
Details of event:
Location: Bike Safe Bike Smart Cycling Program School Grounds cycling and
o!ser"ational "isit to the Great South #oad intersection
Start date: $% &une $'(% )ime: "arious
*inish date: $+ August $'(% )ime: "arious
PARTICIPANT INFR!ATIN FR!
Please complete these details:
,ame Student -.
Address
)elephone /o!ile
0ear or class le"el Age
*orm )eacher
*amily .octor ,ame )elephone
Address
Community Ser"ices Card num!er
/edic Alert num!er 1if applica!le2
T"I# FR! R A CP$ !%#T &E TA'EN N T"E E(ENT) A CP$ #"%*D &E RETAINED &$
T"E #C"* CNTACT)
E!ER+ENC$ CNTACT DETAI*# 1please pro"ide at least $ sets of contact details2
Contact (: 3mergency Contact
,ame: #elationship:
Address:
.ay Phone: 3"ening Phone:
#mit,s Avenue !iddle #c,ool
Class -A
&ike #afe &ike #mart Cycling Program
/o!ile:
Contact $: Alternati"e contact
,ame: #elationship:
Address:
.ay Phone: 3"ening Phone:
/o!ile:
To .e read and signed .y adult assistant or /arent0caregiver of c,ild /artici/ant)
Parental Consent
- agree to my child/myself taking part in the Bike Safe Bike Smart e"ent and ha"e recei"ed sufficient
information on 4hich to !ase a decision5 - agree to their/my participation in the acti"ities descri!ed5 -
ackno4ledge the need for them/me to !eha"e responsi!ly5
Ackno4ledgement of #isk
- ha"e read the Bike Safe Bike Smart e"ent information sheet and - understand that there are risks
associated 4ith in"ol"ement in school 3ducation 6utside )he Classroom e"ents and that these risks
cannot !e completely eliminated5 - understand that the school 4ill identify any foreseea!le risks or
ha7ards and implement correct management procedures to eliminate isolate or minimise those
ha7ards5 - understand my child has !een in"ol"ed in the de"elopment of safety procedures5 - 4ill do my
!est to ensure that -/my child follo4 these procedures5
- kno4 that - am a!le to ask any 8uestions of the school a!out the acti"ities -/my child 4ill !e in"ol"ed in
to gain a !etter understanding of the risks in"ol"ed5 - recognise that participation in such acti"ities is
"oluntary and not mandatory through a 9challenge !y choice:; procedure5 /y child and - !oth understand
that -/they may 4ithdra4 from an acti"ity if -/they feel at risk5 )his must !e done in consultation 4ith the
person in charge5
-n understand that the school does not accept responsi!ility for loss or damage to personal property and
that it is my responsi!ility to check my o4n insurance policy5
,ame:
Signature:
.ate:
; 9challenge !y choice: means the participant chooses their o4n le"el of challenge 4ithin a supporti"e
peer en"ironment5