Participant or Parent / Guardian Participation Consent Form
Details
School/Parish/Organis
ation
Excursion/Camp
Australian Catholic Youth Festival – Maitland Newcastle
Pilgrimage
Date from
2nd December, 2015
I,
Date to
6th December, 2015
parent / guardian of
(name of adult participant or parent /guardian)
(strike-out inapplicable)
(name of underage participant or school student)
Permission
give my:
1. permission for myself / my child named above to participate/attend the
excursion/camp described above, which I understand has been approved by the
Pastoral Support Unit of Diocese of Maitland-Newcastle (organisers) and is
supported by the Catholic Schools Office,
2. consent for myself / my child to travel on or in any form of public or private
transport where such transport is deemed by the organisers to be necessary or
desirable for the safe conduct of the excursion,
3. consent for myself / my child to participate in all activities, outings, trips and
functions arranged as part of this excursion/camp,
4. consent for the organisers, by its servants or agents:
• to seek such medical or dental advice on behalf of myself / my child as seen
fit in the event of accident or illness, and
• if, in the opinion of an attending medical or dental practitioner or medical
officer (‘health practitioner’) myself / my child requires medical or dental
attention or treatment (including but not limited to the administration of
anaesthetic, blood transfusion or the performance of any surgical operation),
to that health practitioner giving such attention or treatment provided that
reasonable efforts are made to inform me of any serious injury or illness,
5. certification that the consent which I have given in paragraph 4 is valid at all
times while myself / my child is in the custody of the organisers while attending
or participating in the excursion,
6. certification that I understand that the organisers will take reasonable care in the
event of myself / my child suffering an accident or illness but that the
coordinators, Diocese or any leader or supervisor will not be responsible for the
costs of any medical or dental attention or treatment administered to my child in
such event nor will it be directly responsible for any act or omission of any health
practitioner attending or treating myself / my child, and
7. certification that if myself / my child should bring or consume drugs, alcohol or
cigarettes or otherwise exhibit behaviour that seriously endangers themselves or
others, I will bear the full cost of return transport home for myself / my child and
any adult supervisor that may be required to ensure the safety of myself / my
child during that transport.
Signature
Date
(Parent / Guardian)
Diocese of Maitland-Newcastle 841 Hunter Street, Newcastle West 2302 I PO BOX 756 Newcastle NSW 2300
Phone 02 4979 1111 Fax 02 4979 1119 ABN 91 605 046 457 Visit us online www.mn.catholic.org.au
Pilgrim Medical Details and Consent Form
The information below is required to assist in case of illness or accident. It is of vital
importance that any illness / disability / limitation be written out clearly on this form. Failure
to do so will severely limit the duty of care that we as a leadership team can provide your
child / yourself. This information must be completed with the utmost accuracy and will be
held in confidence by the Diocese of Maitland-Newcastle.
Participant Name
Health Fund
Participants’ date of
birth
Medicare no.
Position on card
Private health fund
Membership no.
Ambulance cover
Yes
No
Are you / your child in good health?
Yes
No
Do you / your child suffer any chronic illness?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Details
Do you / your child suffer any disability?
Details
Do you / your child suffer any allergy?
Details
Have you / your child suffered any acute illness in the past four
months?
Details
Have you / your child been treated by a doctor in the past four
weeks?
(If ‘Yes’ please attach a medical certificate outlining treatment and statement of your child’s fitness to attend this excursion)
Have you / your child had any major surgery?
Yes
No
Details
Do you / your child have any other condition, illness, disability and or
limitation that the organisers should be aware of? (eg, mental illness,
Yes
No
anxiety, developmental delay, physical disability etc.)
Details
Diocese of Maitland-Newcastle 841 Hunter Street, Newcastle West 2302 I PO BOX 756 Newcastle NSW 2300
Phone 02 4979 1111 Fax 02 4979 1119 ABN 91 605 046 457 Visit us online www.mn.catholic.org.au
Do you / your child need to take any form of medication on the trip?
Medication
Frequency
Medical purpose
Dosage
This medication is to be kept on the
excursion by:
myself / my child
nominated staff member
Do you give permission for Paracetamol and/or ibuprofen
(e.g. Panadol, nurofen) to be administered if needed?
Have you / your child had a Diphtheria Tetanus Toxoid booster
injection?
Yes
No
Yes
No
Yes
No
Year of booster injection if known
Do you / your child have any special dietary requirements?
Diet
Details
Contact details in case of accident or illness:
First Contact Name
Relationship to participant
Emergency
Phone (home)
Phone (mobile)
Phone (work)
Second Contact Name
Relationship to Participant
Phone (home)
Phone (mobile)
Phone (work)
Authority
I understand that the information I provide on this form will be handled in accordance with the
Diocesan Privacy Policy and the Privacy Act 1998.
Date
Signature
(Participant or Parent / Guardian)
Diocese of Maitland-Newcastle 841 Hunter Street, Newcastle West 2302 I PO BOX 756 Newcastle NSW 2300
Phone 02 4979 1111 Fax 02 4979 1119 ABN 91 605 046 457 Visit us online www.mn.catholic.org.au
Photography consent form
Photography Consent
•
I authorise the Diocese of Maitland-Newcastle and the other supervising adults / youth
team members to take photographs of myself / my child while participating in the
activities for the Australian Catholic Youth Festival.
•
I authorise the use of the above-mentioned photographs for media coverage of the
Australian Catholic Youth Festival and promotional material for further youth events.
Name:
Date:
Signed:
To be signed by parent/guardian if participant is under 18 or by participant if over 18.
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Diocese of Maitland-Newcastle 841 Hunter Street, Newcastle West 2302 I PO BOX 756 Newcastle NSW 2300
Phone 02 4979 1111 Fax 02 4979 1119 ABN 91 605 046 457 Visit us online www.mn.catholic.org.au
CONDITIONS OF STAY – OAKS iSTAY ADELAIDE
Please read these conditions carefully. The person signing these conditions ("The Guest")
acknowledges and agrees that these conditions apply and extend to any person (also referred to as
"The Invitee") occupying or visiting the apartment or complex and/or using the facilities in the complex at
the invitation of or with the authority of the Guest.
1. Guest and Invitees are expected to behave in a manner which is conducive to the safety, comfort and
convenience of other guests and residents within the property. The By-laws of the complex and any
reasonable direction of the Manager on Duty must be complied with by the Guest and Invitees. A breach
of house rules may result in eviction of the offender/s at the discretion of the Manager on Duty in
consultation with group coordinators.
2. This establishment, the Diocese of Maitland-Newcastle and its coordinators shall not be liable to any
guest for any loss, damage or destruction to any property brought upon these premises by the said
Guest or Invitees. Without limiting the forgoing, personal property shall include (not limited to): money,
jewelry and other personal effects and motor vehicles parked on the premises.
3. There is a strict NO PARTY POLICY, which will be enforced. The apartment must not be used for any
unlawful purposes.
4. Any loss of apartment keys, security cards/fobs etc. will incur replacement fees of $200 per set,
payable by myself.
5. This is a NON SMOKING building. Evidence of smoking within apartments or the complex common
areas may result in additional cleaning charges payable by the Guest or Invitee.
6. A Guest or Invitee found to have activated a fire alarm without due cause, resulting in the call
out/attendance of the Fire Department may be deemed liable for the payment of any and all associated
fees.
7. If "amendment or cancellation" of this booking occurs at any time during the course of this stay, the
Management reserves the right to charge the nightly rate listed according to the actual length of stay.
8. The Guests signing this Registration Card and/or actually occupying accommodation or utilising other
services shall be responsible for all charges including accommodation costs, additional expenses, item
replacements and necessary costs for any damages or loss to the apartment.
9. All credit card payments for additional expenses incur a service fee of 1.5%.
10. I understand that failure to pay the account for additional expenses will result in a claim for
outstanding debts under the Jurisdiction of appropriate courts in all Australian States and Territories.
I agree that I am personally liable for the payment of the account and agree that any additional charges
for services not billed to the time of departure may be added to my account for settlement. My signature
hereunder indicates that I have noted and accepted the above Conditions of Stay.
Name:
Date:
Signed:
To be signed by parent/guardian if participant is under 18 or by participant if over 18.
Diocese of Maitland-Newcastle 841 Hunter Street, Newcastle West 2302 I PO BOX 756 Newcastle NSW 2300
Phone 02 4979 1111 Fax 02 4979 1119 ABN 91 605 046 457 Visit us online www.mn.catholic.org.au
ACYF Maitland-Newcastle Pilgrimage - Pilgrim Agreement
As pilgrims we are models of Christ and ambassadors for our Diocese and for Australia. This would be displayed
by
- being intentionally courteous to everyone you meet
- watching out for fellow pilgrims’ health, safety and wellbeing
- dressing in a manner appropriate to the occasion
- avoiding language and actions which would be considered offensive
We will be travelling as a community, and should be open to developing authentic relationships with everyone
on the pilgrimage. This would be displayed by
- endeavouring to spend time with many different people
- interacting with different people each time we travel
- being prepared to sacrifice personal interests to engage with the pilgrimage
- ensuring that your ‘travel buddies’ are accounted for when travelling
- keeping to meeting times and places as arranged
- not forming exclusive romantic relationships
- avoiding using headphones for extended lengths of time
- It is mandatory that pilgrims do not participate in activity or behaviour that may bully or harass another
pilgrim
- It is mandatory that there be no sexual activity
- It is mandatory that nobody travel alone
Have a participation mindset. This would be displayed by
- joining with all group events and activities
- attending all the main festival events
- engaging with your small group each day
- not discouraging others from getting involved
Personal space is to be respected. This would be displayed by
- spending free time in public spaces rather in bedrooms
- being sensitive that while some people appreciate physical affection (eg hugs), some people do not
- it is mandatory that males not enter female bedrooms, and females not enter men’s bedrooms except in
case of an emergency
- it is mandatory that under-age pilgrims not enter over-age pilgrims bedrooms, and over-age pilgrims not
enter under-age bedrooms except in case of an emergency
It will be important to maintain healthy habits while on pilgrimage
This would be displayed by
- drinking water regularly
- using sunscreen & sun protective clothing on hot days
- avoiding late nights and losing sleep
- Only using prescription medication as directed
- Not sharing prescription medication with others
- Refraining from smoking cigarettes
- Refraining from being intoxicated in any way
- only having a maximum of two (2) standard alcoholic drinks outside of festival time, for adult participants
not representing a school. Teachers and leaders on duty are not to be under the influence of alcohol.
- It is mandatory that non-prescription/recreational drugs not be used
Diocese of Maitland-Newcastle 841 Hunter Street, Newcastle West 2302 I PO BOX 756 Newcastle NSW 2300
Phone 02 4979 1111 Fax 02 4979 1119 ABN 91 605 046 457 Visit us online www.mn.catholic.org.au
Electronic Communication & Social Networking must be used cautiously.
This would be displayed by
- Being aware that negative statements made on Facebook and twitter etc can be worrying to people back
home when read out of context
- Not spending large amounts of time on the internet, which can be a distraction from relating to other
pilgrims
- following any protocols set by the pilgrimage coordinator regarding communication in the case of a serious
/ critical incident
- ensuring that you have permission of fellow pilgrims to post photos of them online
- pilgrims should refrain from make disparaging statements about the festival, the pilgrimage or other
pilgrims
- it is mandatory that pilgrims refrain from accessing or viewing adult content or material whilst on the
pilgrimage
Misconduct
Any pilgrim engaging or participating in something that is not in line with this code of conduct may be removed from the
Australian Catholic Youth Festival Maitland-Newcastle pilgrimage.
Any pilgrim engaging or participating in something that is illegal under Australian law may be removed from the
Australian Catholic Youth Festival Maitland-Newcastle pilgrimage.
Any costs incurred for leaving the pilgrimage will be costs incurred by the pilgrim.
Signature
I have read this Code of Conduct
____________________________________
Participant Name (Printed)
_________________________
Participant Signature
____________________________________
Parent/guardian Name (Printed)
_________________________
Parent/guardian Signature
Date: ___________________
Diocese of Maitland-Newcastle 841 Hunter Street, Newcastle West 2302 I PO BOX 756 Newcastle NSW 2300
Phone 02 4979 1111 Fax 02 4979 1119 ABN 91 605 046 457 Visit us online www.mn.catholic.org.au