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XG Youth WAKE-O-THON Parent Permission & Medical Information Form
PLEASE FILL IN A SEPARATE FORM FOR EACH PARTICIPANT
On Friday 11th and Saturday 12th November, XG Youth will be participating in a Wake-O-Thon and your signed permission is required for your child to participate. The activity will take place under the guidance and supervision of XG Youth Leadership Team. A description of the event is as follows:
Name of Event:
Description:
Location:
Designated Responsible Person(s):
Contact Details of Responsible Person(s):
Start Date & Time:
End Date & Time:
Cost:
XG Youth Wake-O-Thon
C3 Church Wynyard - 30 Austin St, Wynyard TAS 7325
Nathan & Jacinta Humphreys
N - 0476 988 161, J - 0473 901 012
Friday 11th November at 8pm
Saturday 12th November at 8am
$12.00
I acknowledge that my child participates at his/her own risk in all activities held over the duration of this evnt. I understand that XG Youth (as a ministry of C3 Wynyard) will take reasonable steps to provide a safe environment for my child and to ensure that all equipment supplied by them for all activities is of a reasonable standard.
I acknowledge that XG Youth (or C3 Wynyard) will not be liable for any injury that may be suffered by my child.
I hereby agree to indemnify XG Youth (and C3 Wynyard) against any and all claims arising from, or in connection with, any injury that may be suffered by my child, or that my child may cause to another person, as well as any loss or damage to property, equipment or personal effects belonging to my child, or any other person.
I agree that XG Youth (or C3 Wynyard) may authorise, on my child's behalf whatever medical treatment he/she may require (this includes, but is not limited to, ambulance attendance and hospital treatment) and I agree to pay all medical expenses incurred.
In the event of my child greatly misbehaving, I give permission for their emergency contact to be notified. In addition, if it is no longer possible to have them at the event I agree that they will be collected by a family member or guardian, or be driven home by a responsible adult in the event of a family member or guardian being unavailable.
*
Indicates required field
Participants Name
*
First
Last
PARTICIPANT MEDICAL INFORMATION
PLEASE NOTE: if the participant is a regular XG Youth Attendee and have already submitted this information you can leave the description boxes blank
Do you have any food allergies or dietary restrictions?
*
Yes (If yes, please specify below)
No
Description of any food allergies or dietary restrictions:
*
Do you have any medical conditions or concerns that we should be aware of?
*
Yes (If yes, please specify below)
No
Description of any medical conditions or concerns
*
Are you allergic to any medications or anything not mentioned as food allergies above?
*
Yes (If yes, please specify below)
No
Description of any other allergies
*
Please outline any relevant medical procedure/medications required that relate to any of the above-mentioned information:
*
PHOTOGRAPHY & VIDEO INFORMATION
As part of attendance at
XG Youth
, I give permission for my child to have their photo/video taken and stored by C3 Wynyard (in accordance with the Privacy Act of TAS). Video footage and photographs will be taken to record youth events and may be used to promote C3 Wynyard, XG Youth and its various youth activities in both print and digital formats, including a website.
You may withdraw this permission at any time in writing. please sent to C3 Wynyard (30 Austin St, Wynyard TAS 7325 or
[email protected]
)
Photography/Video Agreement
*
Yes
No
PARENT/GUARDIAN INFORMATION
Parent/Guardian Name 1
*
First
Last
Parent/Guardian 1 Emergency Contact Number
*
Parent/Guardian Name 2
*
First
Last
Parent/Guardian 2 Emergency Contact Number
*
By clicking the button below I agree to the terms and conditions listed above.
I AGREE