DEVONPORT CITY COUNCIL:
SCHOOL HOLIDAY ACTIVITY PROGRAM
School Holiday Program Consent and Medical Information Form


This form is to give permission for your child to attend Council’s School Holiday Activity program;
and
To provide medical information that might be needed in case of emergency.
Please complete and return this form to the Devonport City Council Best St Office prior to
Friday 8th April. Alternatively you can hand the form in to the Council Officer in charge on
the morning of the first day of the program.
Details
Dates
GRADE 3/4 From: 04 July 2016
To: 07 July 2016
Location(s) :
As detailed on the attached information.
Brief Description:
School Holiday Activity Program (see attached information for full details)
Council Officer(s) in charge: Axel Verschuren (Recreation Officer)
Fabio Pizzirani (Sport & Recreation Development Coordinator)
Personal details
Name of participant:
Home address(es) :
…………………………………………………………………
…………………………………………………………………
………………………………………………………………… Date of birth:
…………………………………………………………………
…………………………………………………………………
Emergency contacts for this program
Name
Relationship
1.
2.
3.
Phone (home) or email
Doctor
Phone
Medicare Number
Private Health Fund
Mobile
Address
Number
Tablets and Medicine (Please tick)
Is your child taking any tablets and/or medicine?
Yes
No
If Yes please state name of medication, dosage, etc. and answer the following two questions:
____________________________________________________________________________
Have you completed an Administration of Medication Authorisation? Yes
* No
Has your Doctor/Pharmacist/Practice Nurse completed an Administration of Prescribed Medication
Authorisation?
Yes
*
No
* The completed forms must be attached.
Please tick if your child suffers any of the following:
Asthma
Fits of any type
Heart Condition
Dizzy spell
Sleep walking
Bed wetting
Blackout
Migraine
Travel Sickness
Please indicate if (and what) your child is allergic to:
Any drugs (including Penicillin):
Foods (e.g. nuts, etc):
Any other relevant information:
Consent Form
Medical:
In the event of accident or illness when it is impracticable or impossible to communicate with me, I
authorise the officer(s) in charge or their delegate to:
 Consent to such medical or surgical treatment as may be deemed necessary
 Administer such first aid as may be judged to be necessary.
Participation:
I consent to my child’s participation in these activities. I have been fully informed by the Council of the
arrangements made for the conduct of this program. I understand that the program includes activities that
may involve some risk as set out in the attached program.
I note that the activities include water based activities including swimming, water slide, aqua group fitness
and water safety lessons. This consent covers my child participating in these water based activities as well.
Expenses:
I agree to my child returning home if necessary, in the event of illness or injury, and to pay any expenses
involved or to come and collect my child from the program.
I acknowledge that during the program, acceptable standards of behaviour will be expected of the
participants.
I understand that my child may be sent home in the event of serious misbehaviour during the activities. I
further understand that in such circumstances I will be informed and that any costs involved will be my
responsibility.
I agree to reimburse the Council for any wanton damage caused by my child.
I agree to reimburse the Council for any hospital, medical or ambulance expenses incurred by the Council
on behalf of my child.
Parent/Carer: ……………………………………….
Name
Date: ……………………………….
………………………………………..
Signature
Program Details:
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
9:00 am - 10:30 am
Spilt into 2 groups
Group 1: Judo
(at the Devonport Rec
Centre)
Group 2: Futsal (at the
Devonport Rec
Centre)
Spilt into 2 groups
Group 1: Gymnastics
(at the Devonport Rec
Centre)
Group 2: Basketball
(at the Devonport Rec
Centre)
Spilt into 2 groups
Group 1: Police Station
Tour (at the Devonport
Police Station)
Group 2: Fire Station
Tour (at the Devonport
Fire Station)
Bootcamp at Don
College
10:30 - 10:45 am
Morning break
Fruit & water included
Morning break
Fruit & water included
Morning break
Fruit & water included
Morning break
Fruit & water included
10:45 - 12:15 pm
Spilt into 2 groups
Group 1: Futsal
(at the Devonport Rec
Centre)
Group 2: Judo
(at the Devonport Rec
Centre)
Spilt into 2 groups
Group 1: Basketball
(at the Devonport Rec
Centre)
Group 2: Gymnastics
(at the Devonport Rec
Centre)
12:15 - 12:45/1 pm
Lunch
A healthy (but yummy)
lunch and water is
provided. After lunch
we head off to Splash
Lunch (12:15 - 1:00pm)
A healthy (but yummy)
lunch and water is
provided
12:45 - 4:00 pm
At Splash (split into 3
groups)
Group 1: Free swim
Group 2: Aqua group
fitness
Group 3: Water safety
swim lesson
1:15 - 4:00 pm
Ten Pin Bowling
(at Devonport Tenpin
Bowling)
Spilt into 2 groups
Group 1: Fire Station
Tour (at the Devonport
Fire Station)
Group 2: Police Station
Tour (at the Devonport
Police Station)
Bootcamp at Don
College
Lunch
Lunch (12:15 - 1:00pm) A healthy (but yummy)
A healthy (but yummy)
lunch and water is
lunch and water is
provided. After lunch we
provided
head off to Splash
1:15 – 4pm The Big Big
House for Laser Tag,
Rock Climbing, and free
play
At Splash (split into 3
groups)
Group 1: Free swim &
water slide
Group 2: Aqua group
fitness
Group 3: Water safety
swim lesson
DEVONPORT CITY COUNCIL
44-48 Best Street Devonport
Phone 03 6424 0516
Email [email protected]