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Microsoft word - sail training consent.doc
Parental Consent Form To be filled in and signed by parent/guardian of Sail Training participant. This page not required for adults. I hereby give consent form my child (please name child)______________________ to participate in the Sail Training Program conducted by Deviot Sailing Club Inc. In the event of accident or illness, when it is impracticable or impossible to communicate with me, or my emergency contact, I authorise the adult in charge to consent to my child receiving such medical or surgical treatment as may be deemed necessary. I give permission for my child to receive such treatment as indicated below (please tick appropriate boxes):
At the nearest Public Hospital or Government Health Centre
At my private doctor or clinic. Dr/Clinic ____________________________
Address: ___________________________ Phone: ____________________
I give permission for my child to be transported there by private car, taxi or
ambulance. I agree to pay any charges arising from this transport.
I consent to Panadol to be administered by authorised personnel, if deemed
I agree to notify any changes necessary to the Health Information Sheet for my child subsequent to filling out this form. If such changes are not forwarded, I understand that I may not be able to hold Deviot Sailing Club Inc. liable for any situation that may arise due to lack of information. I am aware that Sail Training will include water activities such as sailing, swimming, and being a passenger on motorboats. Signature of Parent or Guardian: _______________________________________ Full Name of Parent or Guardian: _____________________________________ Date: ___________________________
Adults’ Authority (for adult trainees)
In the event of accident or illness when it is impracticable or impossible to communicate with my emergency contact, or me, I authorise the officer in charge to consent to me receiving such medical or surgical treatment as may be deemed necessary. Signed: ________________________________________ Full Name: _____________________________________
Physical impairment (please specify)_______________________________________
Other ailment (please specify)____________________________________________
Specify Penicillin allergies_________________ Bites/Stings Other known allergies (specify)____________________________________________
Please specify name of drug Dosage and frequency
Headaches/Migraines – What if any pain relief is taken?________________________
Please specify any special needs:_________________________________________ ____________________________________________________________________ Privacy statement: The information on this form will only be used by the Club for the purposes of providing the sailing activities and in the event of an emergency.
VNG Instructions As requested by your doctor, you have been scheduled for a test called Videonystagmography (VNG) which is a test of inner ear and central motor function. The test will take approximately 1 ½ to 2 hours and is not painful. Please follow the instructions below to ensure your test results will be valid. The appointment time reserved for your test is critical. All testing
WACV 2012 Organizing Committee General Chairs Terry Boult, Univ. Colorado at Colorado Springs Walter Scheirer, Univ. Colorado at Colorado Springs Program Chairs Michael Brown, National University of Singapore Ram Nevatia, University of Southern California Luc Vincent, Google Publications Chair Anderson Rocha, UNICAMP Registration Chair Ginger Boult Program C