Permission form

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The Department of Education, through Strathpine State School, is collecting personal information in accordance with Education (General Provisions) Act 2006 in order to maintain student permission records. The information will only be accessed by Department of Education. The information will not be given to any other person or agency unless consent is provided.

Please complete all sections of this form.

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Child's name *

Class *

Excursion name *

Excursion date *

Payment *

I have paid online or via QParents.

Please deduct payments from Centrelink as per agreement.

Please deduct from existing credit.

No payment required for this activity.

Student medical details *

I have completed and returned the medical consent form advising new medical condition or information (student medical details can be viewed via QParents).

Student medical details have not changed.

Refund *

Yes

I understand that if my child is away on the day of the activity no refund will be provided unless a medical certificate is provided. (Refunds will be provided if the activity is cancelled).

Parent/Carer name *

Date *

Swimming ability (Please complete for swim carnivals/surf skills/swimming lessons) *

Please give an indication of swimming ability / limitations or special considerations.

Behaviour *

Yes

I understand that if my child demonstrates behaviour that is not responsible, they are a danger to themselves, other participants and the success of the program or my child refuses to abide by set responsibilities I shall be contacted. I understand my child may need to return to school or home and I am responsible for their transportation from the camp/excursion location.

Activity risks insurance *

Yes

The activity outlined above carries an inherent risk of physical injury occurring. Please note that the Department of Education does not have personal accident insurance cover for students. If your child is injured as a result of an accident or incident, all costs associated with the injury, including medical costs are the responsibility of the parent/carer. Some incidental medical costs may be covered by Medicare. If you have private health insurance, some costs may be also be covered by your provider. Any other costs must be covered by parents/carers. It is up to all parents/carers to decide what types and what level of private insurance they wish to arrange to cover their child. Please take this into consideration in deciding whether or not to allow your child to participate in this activity. I understand and acknowledge the above.

I understand that by submitting this form I give consent for my child to participate in the activity detailed. *

Yes

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