Holiday Camp Medical Form

PURE TENNIS HOLIDAY PROGRAM ENROLMENT DETAILS FORM:

All information on this form must be given in full

The following information is confidential. Please ensure that you notify us of any changes of address or phone numbers.

Name*

First NameLast Name

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

CHILD/RENS DETAILS

	Surname	Given Name	Date of Birth	Age	Male/Female
Child No.1
Child No.2
Child No.3
Child No. 4

We regret that we are unable to care for sick children or
children with contagious illnesses.

PLEASE NOTE: If your children are on any medication you will need to complete an ‘Authority to Give Medication Form’ which can be requested from proshop@puretennis.com.au

Is your child up to date on immunisations?*

YesNoUnsure

Does your child/ren suffer from any allergies?*

YesNoUnsure

If yes to either or both, Does your child/ren have an auto injection device (EpiPen)?*

YesNoUnsure

What is the child/ren allergic to?

What are the triggers?

If the child suffers from Anaphylaxis you must fill in ‘CC SF 30 Anaphylaxis Emergency Action Plan’ or an action plan provided by your doctor to ensure that the centre has the best chance of responding to your child in an emergency

Does your child/ren suffer from Asthma?*

YesNoA little

If yes, have you emailed a copy of the Asthma Action Plan to proshop@puretennis.com.au*

YesNo, but I will ASAPN/A

Please provide details of any dietary restrictions/sensitivities for any child

Name of person authorised to collect:*

First NameLast Name

Relationship to child:*

Are there additional people who are allowed to collect?

Yes - Please add their information at the end of the documentNo

Please note that we will not (under any circumstances) allow any person to collect your child/ren other than those listed. Alternate arrangements will only apply where proper notification from you in writing is received on that particular day. Please include parent’s names on the list.

By enrolling my child/ren in the Pure Tennis Ferny Hills School Holiday Camp, I agree to the following conditions:

1. Although every care will be taken, Pure Tennis Ferny Hills Staff and Program Leaders are free from all responsibility for accidents or loss of property in connection with any child’s participation.

2. I hereby agree that for excursions that are within walking distance from the centre or accessible by public transport the Holiday Camp Leaders have permission to escort/walk my child/ren to and from the advertised excursion venue/s& accompany them on public transport to and from the venue.

3. Pure Tennis Ferny Hills reserves the right to suspend or expel children from the Holiday Camp Program for misbehavior that is deemed inappropriate. NOTE: in the event of suspension or expulsion from the Program, it is the parents’ responsibility to have the child collected immediately. No monies will be refunded for days paid for the remainder of that week following suspension or expulsion from the Program.

4. Pure Tennis Ferny Hills reserves the right to refuse any person entry to the School Holiday Camp as decided by Pure Tennis Ferny Hills Management.

5. I hereby agree to my child being recorded in centre for security purposes only.

6. I hereby agree/disagree to photo’s of my child/ren being taken during the program for advertising and centre purposes.(please circle your preference)

Authorisation

In the event of an accident or illness suffered by my child/ren, I understand that the organisers of the Pure Tennis Ferny Hills School Holiday Camp will try their best to contact me (the parents/guardian). When it is impractical or impossible to communicate with me (the parent/guardian), I authorise the organisers of the Pure Tennis Ferny Hills School Holiday Camp to obtain on my behalf, such medical or surgical treatment as may be deemed necessary and in the best interest of the child/ren. I also agree to pay all expense associated with the treatment given to my child/ward.

Declaration

I declare that the information above is complete and accurate, and I have read, understood and agree to the conditions outlined above.

I understand and agree that all times my child/ren shall be at my own risk and I will not hold FHTC Pty Ltd or its staff liable for any personal injury which may result to my child or loss of property except for any liability by FHTC Pty Ltd if it fails to render its services with due care and skill or supplies any material in connection with those services which is not reasonably fit for the purpose for which they are supplied.

Date*

Date

Signature*

Additional information: