Harrow Neighbourhood House School Holiday Program

This form is required to be completed by the parent/guardian of any person under 18 who would like to participate in the Harrow Neighbourhood House School Holiday Program which is a program managed by the Harrow Bush Nursing Centre. All information on this form is treated strictly confidential and is valid for the calendar year of submission, covering all activities of the school holiday program of that particular year. If there are any changes that occur to the information provided after this form is submitted, please advise the Harrow Bush Nursing Centre as soon as possible. If you indicate on this form that your child has a health condition that requires an Action Plan for example Anaphylaxis or Asthma, this is required to be emailed separately to info@hbnc.org.au. If you have any concerns or questions, please contact us on (03) 5588 2000.

PARTICIPANT INFORMATION

Childs Name

Street Address

Town

Postcode

Date of Birth

Gender

Male

Female

Other

Indigenous

Yes

No

I prefer not to disclose

PARENT/GUARDIAN INFORMATION

Parent/Guardians Full Name

Street Address

Town

Post Code

Phone - Home

Mobile

Work

Email

Relationship

EMERGENCY CONTACT INFORMATION

Please provide details of people we can contact in the event of an emergency. Do not include the person above.

Full Name

Phone - Home

Mobile

Work

Email

Relationship

MEDICAL INFORMATION

Do you have ambulance cover?

Yes

No

Do you have a Healthcare Card?

Yes

No

Medicare No

Tetanus

Yes - see next question.

No

If 'Yes', what was the year of Immunisation

Is your family a member of the Harrow Bush Nursing Centre?

Yes

No

If not and you are interested in becoming a member, please see Reception at the centre to discuss the benefits of membership to the Harrow Bush Nursing Centre.

Has your child been diagnosed with any of the following conditions (check the boxes)?

NOTE: If you have selected any of the options above, and you have a Medical Action Plan which we need to be aware of, please email a copy of this plan to info@hbnc.org.au or bring the plan/s into the Harrow Bush Nursing Centre in person.

If you selected 'Other', please provide details here.

Does your child have any other allergies we should be aware of?

Yes

No

If 'Yes', please provide details here.

Does your child have any diet requirements?

Yes

No

If 'Yes', please provide details here.

Are there any other medical conditions that staff need to be made aware of that may impact on the undertaking of an activity?

Yes

No

If 'Yes', please provide details here.

BEHAVIOURAL INFORMATION

Does your child have any behavioural issues that impact on their ability to enjoy and participate in the program or may impact on other participants’ (e.g. aggression, violence, poor social skills, inability to follow direction)? If 'Yes', please specify here.

MEDIA CONSENT

At the request of Harrow Bush Nursing Centre, I hereby consent to the reproduction of photographs in which my child appears, in any Harrow Bush Nursing Centre publications, displays or paid advertising relating to the promotion of the Harrow Bush Nursing Centre and the School Holiday program: also in any publications (including the internet, newspapers and magazines) produced by any other agencies to which the Harrow Bush Nursing Centre might supply the photographs for the general purpose of the promotion of the Harrow Bush Nursing Centre and School Holiday Program.

Parent/Guardian Name

To provide your consent, type here the words, 'I Agree'.

Date

PARENT/GUARDIANS CONSENT/RELEASE

Please check these boxes below to confirm you agree. If you do not or are unable to check ALL the boxes, your child may not be able to participate in the school holiday program. We will contact you to discuss the options.

I give consent for my child to take part in the activity/s by Harrow Bush Nursing Centre (HBNC). I have read and fully understand all the additional information.

I agree that HBNC will not incur any responsibility or liability for any accident/injury/damage to/loss of property from my child during the activity.

I authorise HBNC to obtain medical/ambulance assistance in the case of an emergency involving my child.

I understand if my child is identified with a potential communicable disease a nominated guardian will be required to pick my child up from an activity, or alternative transport arrangements will be made at my cost.

I also agree to supply my child with all necessary medication and understand that staff cannot administer medication to my child.

I understand and accept that it is my responsibility to advise HBNC of any changes to the information supplied.

Parent/Guardian

To provide your consent, type here the words, 'I Agree'.

Date

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