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: _____________________________________ General Information
Physical impairment (please specify)_______________________________________ Other ailment (please specify)____________________________________________ Known Allergies
Specify Penicillin allergies_________________ Bites/Stings Other known allergies (specify)____________________________________________ Current Medications
Please specify name of drug Dosage and frequency Headaches/Migraines – What if any pain relief is taken?________________________ Special Needs
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.

Source: http://www.deviotsailingclub.org.au/pdf/sailtrainingconsentform.pdf