GUNDIWINDI LODGE CAMP

(Team 3 Camp – Monday August 30th-Wednesday September 1, 2010)

Permission and payment form

(To be completed and returned to school with the medical form)

I give permission for my child ____________________________________

to attend the Team 3 Camp at Gundiwindi Lodge from Monday 30th August to
Wednesday 1 September 2010. On the Wednesday (1st September) I am aware that my
child will also attend the excursion to Healesville Sanctuary.

Please note that the payment amount for the excursion is $200.50 (EMA $166.75).
Payment can be made by using the attached payment document by Friday, August 20th.
If, for whatever reason, this due date is not achievable, please contact Graham Stevenson
(school principal) to arrange alternative payment method.

Signed __________________________________________ parent/guardian

Date _______________________________

I authorise the teachers in charge to consent, where it is impracticable to communicate

with me, for my child to receive such medical treatment and/or surgical treatment as may
be deemed necessary.

Contact name/s and telephone numbers for the dates 30th, 31st August and 1st September,
2010.

_____________________________________________________________

_____________________________________________________________