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| Please complete this form by Friday 28 November 2014. |
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| * First Name: | | | | * Last Name: | | | | * Mailing Address: | | | | * City/ Suburb: | | | | * State: | | | | * Postcode: | | | | Home Phone (with area code): | | | | * Email Address (This will used for all future correspondence): | | | | Participant's Mobile (if any): | | |
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| Please complete the following: |
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| State Electorate: | | | | Federal Electorate: | | |
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| Parent / Guardian details |
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| * Name: | | | | * Mobile: | | | | Work Phone (if any): | | | | * Email: | | |
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| Name: | | | | Mobile: | | | | Work Phone (if any): | | | | Email: | | |
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| Emergency Contacts (2 contacts required): |
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| * Name: | | | | * Contact Number: | | | | * Relationship to participant: | | |
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| * Name: | | | | * Contact Number: | | | | * Relationship to participant: | | |
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Medical Information:
NB. All Information will be treated confidentially |
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| Blood type: | | | | * Medicare Card Number: | | | | * Placement on the card (i.e. 1,2,3): | | | | * Expiry Date: | | | | Pharmaceutical Benefits No: | | | | Private Health Insurance Fund: | | | | Policy Number: | | |
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| Please list regular medication taken (if any): | | |
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| Do you require assistance to take required medication? |
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| * Do you suffer from travel sickness? |
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| For participants who are under 18
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Do you give permission for your child/ward to be given paracetamol (Panadol) e.g. for headaches, sore throats etc?
(NB. Gondwana Choirs’ employees or volunteers will only supply paracetamol. For all other conditions or ailments, such as allergies, hayfever, colds etc choristers must have their own medication) |
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| Additional medication to be take during attacks: | | | | Best peak expiratory flow reading (if known): | | | | Peak flow reading requiring extra medication: | | |
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Other Medical Conditions:
NB. Please be advised that in some circumstances, it may be a condition of your participation in NCS that you attend with a carer.
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| Please tick the box if you have any of the following: |
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| If you have marked any of the above, please provide details in the box below: | | |
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| * Have you ever experienced an anaphylactic reaction? |
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| If yes, please detail the cause and the severity of the reaction including an anaphylaxis management plan. Please advise us if you carry an EpiPen. | | |
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| If you have answered yes to any of the above, please provide details below: | | |
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| Do you have special food / dietary requirements other than food allergies outlined in the above section? |
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| If dietary restrictions are in place, please specify and identify foods that can be eaten: | | |
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| Are you a confident swimmer? |
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| Gondwana Choirs aims to provide each child with a rewarding musical experience. If there is any personal information that you feel is relevant (e.g. fears, anxiety, personal difficulties with other choristers, learning difficulties such as dyslexia, dyspraxia, ADHD, ADD, Asperger’s Syndrome and autism ) or anything else you would like us to know about your child/ward, please provide the details below. This information and any associated management plan is a very valuable resource to assist staff and volunteers to meet the needs of all choristers. | | |
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| Permission & Disclaimer for Gondwana National Choral School 2015
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1. I give permission for my child/ward to be a participant of the Gondwana National Choral School in 2014 ("The Program" and to participate in rehearsals, performances and social activities associated with the the Program. (This clause applies to participants under the age of 18).
2 I have provided Gondwana Choirs with all the information that is necessary for employees and volunteers of Gondwana Choirs to plan safe and reasonable heath care support for me / my child / my ward. This includes, if relevant, any activity modifications I / my child / my ward may require for medical reasons
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3. I agree to inform the employees of Gondwana Choirs of any changes to my / my child / my ward 's health, not indicated on this form, at a time prior to the commencement of activities throughout the Program. 4. In the event of any accident or illness throughout the duration of The Program, where contact with the child/ward's parent/guardian is impractical or impossible, I hereby authorise the obtaining on my behalf of any medical, surgical and dental assistance for me that a registered medical practitioner considers necessary. I further authorise qualified practitioners to administer anesthetic to me /my child / my ward if such an eventuality arises. I undertake to pay any medical, ambulance or dental fees and/or costs incurred in this regard
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5. I understand that Gondwana Choirs and its servants, agents and officers will under no circumstances, be held responsible for any personal injuries, damage or loss to me /my child / my ward that may occur: a) in the course of traveling to and from the Program; and/or b) during the attendance of The Program and/or throughout the course of my / my child / my ward 's stay at venues for the duration of The Program; and I will not bring any legal claim on my child/ward's behalf against Gondwana Choirs and its servants, agents and officers in the event that any personal injury, damage or loss is sustained by me / my child / my ward in such circumstances outlined in 5(a) and 5(b) above.
6. I understand that completed Registration Forms are treated with the utmost confidentiality at all times unless a situation arises in which information on the forms must be accessed (e.g. medical emergency / dietary requirements). In these instances, Third Party Providers will be notified of the relevant information in the Form.& Disclaimer for 2015 Gondwana National Choral Program
7. I consent to Gondwana Choirs filming, recording and/or photographing me / my child / my ward ("Footage") for promotional, marketing and other purposes associated with The Program. I agree to, and permit Gondwana Choirs and its nominees and sponsors to using the Footage and my / my child / my ward 's name, image and likeness. I agree that Gondwana Choirs has no liability or obligation of any nature to make payments to me at any time in respect of the Footage, or any literary, dramatic, musical works or sound recordings ("Original Works") created by me /my child / my ward in the course of their participation with Gondwana Choirs. I acknowledge that Gondwana Choirs is not obliged to publish or otherwise use the Original Works or Footage or any part of them. I consent to Gondwana Choirs and its nominees and sponsors without limitation using, reproducing, exhibiting, editing, adapting, compiling with other works or materials, transmitting, broadcasting, publishing and distributing the Original Works or Footage in any media and any territories at its discretion. I agree that ownership of any intellectual property rights in the Original Works or Footage, and all works derived from or created under the Original Works or Footage, vest in Gondwana Choirs. To the extent that any such intellectual property rights vested in either me / my child / my ward, these will be assigned, upon their creation, to Gondwana Choirs. To the full extent permitted by law, I consent to the doing of anything in relation to the Original Works and Footage that (but for the consents provided in this letter) would otherwise infringe any moral rights, performers’ rights or similar no assignable personal rights that I / my child / my ward might otherwise have including but not limited to publishing the Original Works and Footage without attribution and modifying/adapting the Original Works and Footage. I agree to execute all documents and do all things required by Gondwana Choirs for the purpose of giving effect to the above requirements.
8. I understand that I/ my child / my ward are not to consume any illegal substances during the duration of the Program. I understand that I / my child / my ward are not to consume alcohol during the duration of the ProgramI understand that I / my child / my ward are not to offer or purchase alcohol or illegal substances for any other participants in the Program. I realise that if I/ my child / my ward breach this understanding I/ my child / my ward will be asked to leave the Program immediately. If I am a participant 18 years and over, I understand that I am not to consume any alcohol until all scheduled program activities of the day have been completed and that moderation must be observed.
9. I agree that I/ my child / my ward must attend all scheduled activities during the Program. I understand that, after discussion with me by Gondwana Choirs staff, it may be decided for personal, musical or behavioural reasons that I/ my child / my ward is not suitable for The Program and may be asked to return home. I understand that, if this situation arises, any costs incurred (eg changing return flight home) are to be borne by me.
10. I understand that the Program requires high level of commitment and behaviour from my child / my ward. I have explained to him/her that during the Program, he/she will be required to work hard and participate in all that is going on (we will also have a lot of fun!). There may be an occasion where it is felt that a participant is not coping with the demands of the Program. I understand that after discussion with me it may be decided for personal, musical, orbehavioral reasons that my child/ward is not ready for the Program and may be asked to return home. I understand that, if this situation arises, any costs incurred are to be borne by me. (This clause applies to participants under the age of 18) |
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