Living Waters Lutheran College

Camp and Excursion Risk Assessment Form

Administration
Year 10 Outdoor Education Indoor
Excursion Year Level / Group Year 10 Outdoor Education
Rock Climbing
Day Friday Date 14/05/2021

Departure Time 9:00 Return Time 2:30

Location Mandurah Indoor Rock Climbing: 3/12 Thornborough Road Greenfields WA 6210
Students will travel to Mandurah Indoor Rock Climbing Centre to develop practical skills related to their
roping unit as part of their Outdoor Education studies. Students will participate in activities such as
Excursion abseiling, top rope climbing and bouldering. They will be developing skills such as belaying,
Description communication skills, climbing techniques, knot tying and handling ropes.

(including key activities)

Students will develop skills as part of their performance-based assessment in Outdoor Education.
Rationale for
Excursion

(e.g. links to the

curriculum)

Excursion Leader Ben Clark Number of Staff 3

Number of Students
31 Staff / Student Ratio 1:11
(attach names to form)

Staff Names Ben Clark, Rachael Berlin, Ryan Spencer

Attend school as per normal school day arrangements. During Outdoor Education lessons students are to
go to the Library and complete supplied work.
Arrangements for
students not
attending excursion

Money ☐ Yes Amount: $

Student Dress ☒ Sport ☐ Formal ☐ Casual
required ☒ No

Food/Drink required ☒ Yes Details: Bring a packed lunch and water ☐ No

Transportation

Do you require a bus to be booked? ☒Yes ☐ No

§ If yes, please organise the buses via the Business Office.
§ If using private vehicles, refer to College’s “Use of Private Vehicle” Policy Total number (staff & students) 34

Departure time from the College 9:00 am

No Venue Address Arrival (hrs) Departure (hrs)

Mandurah Indoor Rock 3/12 Thornborough Road Greenfields WA 6210
1 9:30 am 2:00pm
Climbing
2

Arrival time back at the College 2:30pm

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Living Waters Lutheran College
Camp and Excursion Risk Assessment Form

Costs
Cost of Bus(es) $187 Total Cost $900

Cost of Venue(s) $23/student Number of students 31

Other Costs Cost per student

Equipment
First Aid Kit
College equipment /
assets to be taken off
campus

Medical Details

Are full medical records required for this excursion / camp? ☒ Yes ☐ No

If yes, is there a completed College Medical Record and Consent form for all students attending the
☒ Yes ☐ No
excursion / camp?

If full records not required, a summary of medical information is required. ☐ Yes ☒ No

Are First Aid facilities readily available on site? ☒ Yes ☐ No

If not, is a First Aid kit readily available to the excursion leader? ☒ Yes ☐ No

Communication

Emergency Services (Local) Main College Numbers (08) 9593 1211

Principal 0433 583 114

000 or 112 from a mobile phone Head of Secondary 0422 428 899

Head of Primary 0452 160 174

Excursion Leader Ben Clark: 0438052781

Rachael Berlin: 0476138464

Venue 1 9581 7465 Other Excursion Staff
Ryan Spencer: 0405588760
Venue 2 Other Excursion Staff

Venue 3 Other Excursion Staff

Students with Special Needs

Student Name Management Requirements Parent Contacted

☐ Yes ☐ No

☐ Yes ☐ No

☐ Yes ☐ No

☐ Yes ☐ No

Learning Support Staff

☐ No ☐Yes (if yes, staff names);
Required

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Living Waters Lutheran College
Camp and Excursion Risk Assessment Form

Risk Management / Workplace Health and Safety Assessment

Is the application for Risk Management section complete? ☒ Yes ☐ No

If no, indicate why?

(i.e. limited risk, assessment waived)

Are the proposed control measures appropriate for the hazards identified? ☒ Yes ☐ No

If no, what additional control measures

are required?

Assessed by Principal

Name Signature Date

As Excursion Leader, I understand my responsibilities as outlined in the College Staff Handbook.

Name Signature Date

Attached to Application

☐ Yes ☐ No Permission Letter

☐ Yes ☐ No Full List of Students

☐ Yes ☐ No Full Itinerary (if transport arrangement section inadequate e.g. Tour/Trips)

☐ Yes ☐ No List of Contact Details (if communication section is inadequate)

☐ Yes ☐ No Summary of Student Medical Details (prior to departure)

Recommendations
HOLA/Line Manager Signature Date

Head of School Signature Date

Excursion Approval

Excursion is:
☐Approved ☐Not approved ☐Requires further discussion or changes

Principal/Deputy Signature Date

☐ Yes ☐ No Copied and returned to excursion organiser

☐ Yes ☐ No Copy to Accounts if Applicable

☐ Yes ☐ No Excursion added to calendars/Daily Organiser

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Camp & Excursion - Parent Information
Consent Form

Year Level / Group Year 10 Outdoor Education Teacher in Charge Ben Clark

Activity Indoor Rock Climbing

Students will develop skills and be assessed as part of their performance-based assessment in Outdoor
Purpose
Education.
Destination / Venue Mandurah Indoor Rock Climbing

Date of Departure 14/05/2021 Time of Departure 9:00 am

Date of Arrival back Time of Arrival back
14/05/2021 2:30 pm
at College at College
Method of Transport Bus with seatbelts fitted Bus without seatbelts fitted Private vehicle

Requirements Details
Sports uniform
☒Uniform
Packed lunch
☒Food
Water
☒ Drink
Student
Requirements ☐ Sun Protection

☐ Money
☐Access to shops /
canteen
☐Other

☒ Cost of this activity has been included in the College Fees.

☐ Cost of this activity is $ and will be included in the Term account

Cost ☐ Cost of this activity is $ and payment is to be made at Parent Reception

Note: Students making late withdrawals from an activity will normally be charged unless a replacement is found
or satisfactory explanation is accepted. If there are any problems with respect to the participation of your child in
the activity, please contact the Teacher in Charge.

Return Consent Form and Emergency Information

Please Return By: 12/05/2021

If you have any questions regarding this activity or your child’s participation in it, please contact the Teacher in charge
at the College. I give permission for my child to attend this activity.

Parent Signature Date

Student Agreement
I acknowledge that I will represent myself, my fellow class members and the College to the best of my ability at
all times. I realise that the Student Expectations, as set out in the Student Handbook, will continue for the
duration of the excursion.
Student Signature Date

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Living Waters Lutheran College
Camp and Excursion Risk Assessment Form
Emergency and Medical Information

Student Name Date of Birth

Address Postcode
Phone Number
Gender ☐Male ☐ Female
(Parent/guardian)

If there is no change to your child’s current medical information at the school, please
Medical Information tick the box alongside. If there are changes, please fill out the details below.
☐

Medicare No Other Health Care

(Specify)

Doctor’s Name Phone No

1st Contact Person in Emergency Relationship
(24 hour contact if o/night)

Phone (hm) Phone (wk) Phone (m)

2nd Contact Person in Emergency
Relationship
(24 hour contact if o/night)

Phone (hm) Phone (wk) Phone (m)

Does your child suffer from any allergies ☐ Yes ☐ No

If YES – Type,
Severity and
Treatment

Does your child suffer any conditions requiring medication (e.g. Epilepsy,
☐ Yes ☐ No
Asthma)?
Time to be administered at…
Medication Condition Dosage
(E.g. before/after breakfast)
If YES, please
supply details of
condition,
medication, name
and contact number
of treating doctor.

Date of last
occurrence
Has your child suffered any recent illnesses or injuries? ☐ Yes ☐ No
Details:
If YES, give details
of illness or injury.

Current treatment

In an emergency, I authorise the staff Living Waters Lutheran College to consent to my child receiving such
medical treatment as is necessary. Every effort shall be made to contact parents in the event of an incident
occurring with/to their child.
Full Name

Parent/Guardian Signature Date

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Living Waters Lutheran College
Camp and Excursion Risk Assessment Form
Excursion Checklist
PART A - Before you book the excursion:
ü when
Tasks to complete before booking the excursion
completed
Check calendar for dates that do not clash with events already planned eg. School photos, Information Nights, Camps ☐
Determine costs (as per Application for Excursion Form) ☒
Check with Business Office for information required for payments / preferred method of payment. ☒
Check for bus availability (internal and/or external company) ☒
Plan the excursion with any other relevant staff or consultants. ☒
Visit the venue(s) if new venue, outdoors or potential for other changes that affect safe conduct of the excursion. ☒
Complete and submit the Application for Excursion Form, including using the “Risk Management” form. ☒
Excursion Application is approved - a copy from the Principal. ☐

Make the booking – venues and bus

PART B - After you have booked the excursion:

ü when
Tasks to complete after you have booked the excursion
completed
Distribute Parent Consent form (at least 2 weeks in advance) - include details of venue and activity, date, times of ☐
departure from College and arrival back, educational purpose, costs, whether parent helpers are required, if there is
room for them on the bus, details of meals/snacks/drinks that students are to take, appropriate uniform, details of any
risks and management strategies.
Provide a copy of Parent Consent Form to the Main Admin and Middle / Senior Office-. ☐
Organise to take a First Aid Kit from the Admin Office ☐
Book College mobile phone from the Admin Office. ☐
Notify other staff who work with the students:
§ Notify Class teachers
§ Notify Teacher Aide
☐
§ Notify PC Teachers
§ Notify specialist teachers
§ Notify Instrumental Music teachers
Collect Parent Consent forms, check and file. ☐
PART C - The Day of the Excursion:

ü when
Tasks to complete on the day of the excursion
completed
Take the roll on a separate sheet. Hand this to the Front Office. ☐
Take a copy of the separate roll sheet to take with you on the excursion. ☐
Pick up First Aid kit from the Front Office (afternoon before preferred). ☐
Check students are in appropriate uniform. ☐
Reinforce the expectation of normal school rules. ☐
Check condition of interior bus before and after the excursion. ☐

PART D - After the Excursion:

ü when
Tasks to complete after the excursion
completed
Return first aid kits and other College Equipment. ☐
Comment on the adequacy of risk management strategies. Copy to the Principal. ☐
Other notes of improvement or changes for future years (timing, venues, sequence, etc) ☐

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Living Waters Lutheran College
Camp and Excursion Risk Assessment Form
Notes

Incident Occurs

Ensure safety of all people in

area.

§ Nature of Incident
§ People Involved
§ Ambulance called 000. § Time it occurred
§ Keep area clear for emergency services to attend § Location
§ Ensure safety of other students including their return to College § What plans have been
§ Accompanying staff members mobile phone left on for College put in place for the
to contact accompanying staff member. No other calls to be remaining group
made. § Emergency services
§ Office notified. contacted
- School Hours – Warnbro Campus 9593 1211; § Destination of
- After Hours – Principal 0433 583 114; ambulance if known
- HOS 0422 428 899; HOP 0452 160 174 § Support required

§ Office notifies Principal

§ Nominated staff
member accompanies
person to hospital and
informs school which
hospital as soon as
known § Principal and Business Manager notified.
§ Plan put into place to ensure safety of remaining
community and smooth running of school.

§ Staff member provides § Nature of incident clarified.

information back to the § Affected members of the community identified
Principal or nominee in and support personnel identified.
a timely manner

§ Counsellors and support

processes implemented.
§ Staff covered with relief.
§ Admin Officer provides
support to Principal for
school organisation.
§ Family members and others
close to affected person
notified as directed by
Principal or nominee.

§ Principal or nominee informs staff and remaining student community.

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Risk Assessment and Management
Form
Consequences
Activity Type Rock climbing, bouldering, abseiling Likelihood Insignificant Minor Moderate Major Catastrophic
A – almost certain Low + Medium + High Very High Extreme
Activity Location Mandurah Indoor Rock Climbing
B – likely Low - Medium - Medium + High Very High
C - moderate Negligible Low - Medium - Medium + High
Activity Date 14/05/21 D - unlikely Negligible Low - Low + Medium - Medium +
E - rare Negligible Negligible Negligible Low - Low +
Complied by: Rachael Berlin
Need to assess Environmental / People / Equipment Risks

Activity Risk Risk Assessment Risk Controls Level of Risk

No
(Recognised Hazard/Peril)
General Illness or injury.
1 Unlikely
Indirect/remote supervision
2 (includes field work, historic sites,
etc)
(Potential Accident/Injury)
Injury/death
Injury/ separated from group.
Likelihood Consequence (Strategies to reduce or eliminate risk) with Controls
• 1st aid cover accessible and appropriate
• Medical records of all students held by
group leader – provisions for students with
medical needs eg. asthma puffer for
asthmatics, epipens for anaphylaxis.
• Leaders know how to call emergency
services.
Moderate Low -
• Pupils and parents are reminded to bring
individual medication, and this is securely
kept.
• First aid and travel sickness equipment
carried.
• Mobile phones carried by all staff.
• Emergency contacts arranged.
• Check location as suitable for this mode of
supervision.
• Ensure pupils sufficiently briefed and
competent (any individual pupils for whom
indirect supervision not suitable must be
directly supervised).
Unlikely Moderate Low -
• Clear guidelines and emergency
procedures set and understood.
• Pupils remain in pairs or groups (buddy
system – each responsible for named
other).
• Rendezvous points and times set.

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Risk Assessment and Management
Form
• 3Pupils know how to contact staff.

• If coaches have seat belts – staff must

ensure that they are used.
• All students to remain in seats at all times
on school bus.
• Sufficient supervision
Transport accident –
3
bus/coach/train
Injury/death Unlikely Major • Suitable embarkation points used (for Low +
example, coach park, onto wide
pavement).
• Close supervision and head counts during
any breaks in journey and getting on and
off coach.
• Briefing to all pupils about expected
standards and code of behaviour.
• Identify requirements at time of booking
and check during pre-visit and on arrival.
• Check that a fire risk/evacuation
assessment has been completed.
4 Building – Fire/evacuation Injury/Death/separated from group. Unlikely Major Low -
• A group list is held by staff to ensure
registration of whole party after an
evacuation of the building.
• A group list is held by staff to ensure
registration of whole party after an
evacuation of the building.
• From site-specific risk assessment decision
made regarding necessary equipment –
helmets (usual), type of footwear etc.
5 Climbing activities Death, injury. Unlikely Moderate • Close supervision by experienced staff. Low -
• Ropes, or terrain requiring ropes, may only
be used by qualified staff working to an
operating procedure.
• Qualified supervision as above.
• Instruction/monitoring of use of
Equipment failure, inappropriate use equipment.
6
of equipment. Disabling or fatal injury. Rare Moderate Low-
• Equipment used in compliance with
manufacturers recommendations, regularly
checked and log maintained.

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Risk Assessment and Management
Form
• Close supervision, large groups split into
small groups each with leader known to
7 Group control injury, death. Unlikely Moderate pupils. Low -
• Overall leader remains in touch with all
groups and can recall effectively.
• Students will be briefed about keeping a
Moderate - safe distance from others, as per the
8 COVID-19 Potential risk of infection Rare Negligible
Catastrophic government requirements.
• Comply with restrictions held by the venue
• Check in with student during day activities
Moderate -
9 Diabetes management Illness/Death Rare • First aid kit included glucose gel Low -
Catastrophic
• Follow action plan if needed

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