Permission for student to attend

excursion – parent consent form

Questions are followed by answer fields. Use the ‘Tab’ key to navigate through. Replace Y/N or Yes/No fields wit h your answer.

Excursion details - to be completed by school

School name Nemarluk School

Teacher in charge Carmine Adamo Class/Year/Subject TR to Yr 5

Rebecca Gibson -Health and
Jo Lasham Physical
Education
Gabby Woodward

Likely number of children participating 8

Likely number of staff participating 3

Anticipated ratio of educators to children 1:3 approx

A risk assessment has been prepared for this excursion and is available upon request.

Purpose of the excursion

To provide students opportunities to participate in a variety of sports in a fun and in an inclusive

environment. The excursion will also encourage students to explore sporting opportunities in their local
community to participate in.

Details of the destination

Netball Northern Territory

235 Abala Rd, Marrara NT 0812
Opens 8:30am and Closes 4:00pm

Times and dates of the excursion

From date 15/09/2021 Time 10:00am

To date 15/09/2021 Time 1:00pm

Regular outing / reoccurring excursion details - if applicable

Date/s Time/s

Day/s of outing How often will the

outing occur e.g. weekly
for 6 weeks

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 Permission for student to attend excursion – parent consent form
Details of each activity

Students are attending Activate Inclusion Sports Day which is an inclusive day of sports. Students will rotate with
class around the Netball NT venue participating in a variety of sports run by a specified coach of that sport.
Students will develop their Fundamental Movement Skills in a variety of movement sequences and situations. Also,
students will learn to cooperate with others when participating in the different sports and also practise personal
and social skills to interact positively with others.

Student requirements: e.g. sun protection, running shoes

Nemarluk School uniform, running shoes, recess and lunch, drink bottle.

Accompanying adults

Name Position Name Position

Rebecca Gibson Classroom Teacher Carmine Adamo Physical Education

Teacher

Joanne Lasham SESO Gabby Woodward SESO

Planned transport School bus/Hire bus/Town bus/Staff or parent vehicle/Student’s own

vehicle/Walking/Other

Costs associated with the excursion

Excursion costs - $ NA Suggested spending money - $ NA

Teacher in charge Carmine Adamo Form return date 13/09/2021

Teacher in charge Date 07/09/2021

signature
C. Adamo
Principal signature Date

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 Permission for student to attend excursion – parent consent form
Student details - to be completed by parent

Please complete all details below and return to the Teacher in Charge by the return date. Failure to do so
may result in your child being unable to participate in the activity.

Student’s family name Student’s given name

Student’s date of birth Student’s gender Male/Female

Contact details

Parent’s name Emergency contact

Preferred contact Work/Home/Mobile Preferred contact Work/Home/Mobile

Work Work

Home Home

Mobile Mobile

Student’s medical details

Known allergies e.g. drug reactions

Dietary restrictions

Date of last tetanus injection

Is the student under medication? Yes/No

If yes, name medication and attach instructions

Has your child any special medical condition, Yes/No

physical or psychological limitations or cultural
restrictions which may affect her/him whilst
taking part in any activities?

If yes, please provide full details, attach

information if necessary. Please provide any other
information which you believe may help staff
provide the best possible care.

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 Permission for student to attend excursion – parent consent form
Parental consent

Your attention is drawn to the following important points:

• Students are under the teacher’s/supervisor’s authority for the duration of the excursion. A
student may be returned home at the expense of the parent/caregiver if the teacher/supervisor
considers that circumstances warrant such action.
• The Department of Education has a duty of care for students engaged in school related activities,
including excursions and sporting events under its direction or supervision. All reasonable steps
will be taken to protect students against reasonably foreseeable risks of injury or harm.
• Financial responsibility for medical and other costs incurred in emergency situations or where a
decision is taken to return a student home, rests with the parent/guardian of the student. Parents
may wish to take out additional insurance to cover such costs.
• Liability for loss, theft or damage to student property is the responsibility of the parent/guardian
of the student.
• Students are not permitted to transport other students in vehicles regardless of written
permission being provided.
• The parent/guardian is responsible for informing the school/preschool of any change in consent
to their child attending an excursion and of any changes to student medical details.
 Privacy Notice: The Department of Education collects the information on this form in accordance
with the Excursions Policy, and may disclose this information to third parties in connection with
this excursion. Failure to provide this information may result in your child being unable to attend
the relevant school excursion. For further information, or to access the information you provide
on this form please contact your child's school.

Permission is given to attend this excursion Yes/No

Permission is given for school staff to administer Yes/No

first aid if required

Permission is given to secure medical attention in Yes/No

case of illness/accident whilst on this excursion
and I accept responsibility for any costs involved
including ambulance transport if applicable.

I agree to pay the excursion costs outlined above Yes/No

Is your child under the age of 7? Yes/No

If yes, complete Child restraints form.

Does the excursion involve aquatic activities? Yes/No

If yes, complete Student’s swimming ability form.

Parent’s name Date

Parent’s signature

End of form

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Child restraints form

Seatbelt and safety restraint requirements are dependent on the type of vehicle being used. In the NT all
children under seven years of age must be secured in an approved child restraint or booster seat when
travelling in a vehicle. For further information see Child restraints frequently asked questions.

Is a child Yes/No
restraint/booster seat
requested?

If yes, an approved School/preschool/parent/guardian

child restraint/booster
seat will be provided by
the

If required, I agree to Yes/No

provide an approved
child restraint/booster
seat

Parent’s name Date

Parent’s signature

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 Permission for student to attend excursion – parent consent form

Student’s swimming ability form

In relation to the proposed swimming activity in my opinion, my child is:

A non-swimmer: my child is unable to swim Yes/No

A weak swimmer: my child is comfortable and Yes/No

confident in shallow water but is not very strong
or confident in deep water. My child cannot swim
more than 10 meters

An average swimmer: my child is a reasonable Yes/No

swimmer and can swim 25 metres and is confident
in deep water

A strong swimmer: my child is a strong swimmer Yes/No

and can swim more than 50 metres and is
confident in deep water

My child is permitted to go in the water Yes/No

What level has the student achieved in the RLSSA

Swim and Survive Program?

If known provide the date it was achieved

I consent to my child swimming with supervision Yes/No

In addition to parental assessment of a student’s swimming ability, assessment of an individual’s

swimming proficiency is conducted by the school/teacher before participating in any aquatic program or
activity.

Parent’s name Date

Parent’s signature

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