Registration Form for D of E Gold Adventurous Journey


REGISTRATION FORM To be filled out and sent to Laurel Hill Forest Lodge before expedition.

DUKE OF EDINBURGHS AWARD ADVENTUROUS JOURNEY 2017 FOR GOLD STUDENTS

Parent Consent

School Name: ………………………………………………………………….. School D of E coordinator’s name ………………………………………………..…….

Students Name: ………………………………………………………………………………………………………………………………………………………………………….

Address:……………………………………………………………………………………………………………………………………………………………………………………..

Students Email Address: ……………………………………………………………………………………………………………………………………………………………..

Is this a Practice Trek □ or a Qualifier Trek □

I consent to my son/daughter attending the Hume and Hovell Duke of Edinburgh’s Award Adventurous Journey

from _____________________ to_____________________

I am aware that the students will not be supervised at all times during the expedition as part of their requirements for their Duke of Edinburgh’s Award. I have arranged the major forms of transport to and from their home address to Laurel Hill. I also consent to my son/daughter being transported at various times before, after and during the expedition in vehicles driven by staff from Laurel Hill Forest Lodge at Tumbarumba.

Signed: ………………………………………………………………………………………………………………………..…… Date: ………………………

Parents/Carers Signature

Medical Information Form

Students name: …………………………………………………………………………………………………………………………………………………………….……

Medicare Number: …………………………………………………………………………………………………………………………………………………………..…

Parent or Caregiver contact details:

Name: ……………………………………………………………………………………………………………………………………………………………….…………………….

Address if different to above: ……………………………………………………………………………………………………………………………………………………..

Email address: ……………………………………………………………………………………………………………………………………………………………………….…

Home Phone: ……………………………………..…….. Work: ……………….………………… Mobile: ……………………………………………

Emergency contact details: nominated by the parent or caregiver as alternate contact 

Name: ……………………………………………………………………………….……   Phone: ………………………….…. Mobile: ………………………………………..

Family doctor contact details:

Name: ……………………………………………………………………………………………………………………………… Phone: …………………………………………….

Health/ fitness aspects of the child that may require special attention, including existing medical conditions, illnesses or allergies. Outline the treatment for each.

……………………………………………………………………………………………………………………………………………………………………………………………………

Are any medication(s) to be administered during the expeditions? Include name of medication, instructions for administration, time of administration, and any possible reactions.

…………………………………………………………………………………………………………………………………………………………………………………………………..

Outline special dietary needs including possible reaction to inappropriate diet.

………………………………………………………………………………………………………………………………………………………………………………………………….

Furthermore I authorize any officer, member or servant of the Duke of Edinburgh’s award, in the event of any accident or illness to obtain such urgent medical assistance or treatment for my son/daughter, including the administration of any anesthetic or blood transfusion as he or she may consider expedient, and for this purpose to engage any first aiders, ambulance officers, doctors, dentists, nursing assistance or hospital accommodation and hospital fees (other than fees and expenses recoverable by the Duke of Edinburgh Award under any policy of insurance.)

Signed: ……………………………………………………………………………………….Date: ………………………………….

Privacy Advice: The above information is being obtained in case medical assistance is required for your son or daughter over the course of the expedition. Other persons and/or agencies that may be provided with this information are medical agencies such as ambulance officers, nurse and doctors to enable appropriate first aid treatment by providing an accurate medical history of the patient.

PAYMENT:

□ $240.00 per person

□ By cheque made out to ‘Laurel Hill Forest Lodge’ Mail to 1670 Batlow Road Tumbarumba 2653

□ By direct deposit Bendigo Bank Details: Laurel Hill Forest Lodge BSB 633 000 Account No.156987844