Seaside Travels Participant Form

Seaside Travels Participant Form

Application Form
Child's Name

First NameLast Name
Child's Preferred Name
Nature of illness or disability:
Sex

FemaleMale
Child's Date of Birth

MonthDayYear
Date
Child's Height
Child's Weight
Child's Clothing Size
Does your child speak and understand English?

YesNo
Does your child have a passport?

YesNo
Has your child been on an overseas trip before?

YesNo
If yes, please provide details and be specific of areas visited and activities undertaken:

Parent Name

First NameLast Name
Title

Mr.Mrs.Ms.Miss
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Mobile Phone Number
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Business Phone Number
Please enter a valid phone number.

Medical Contact Information: General Physician Name

First NameLast Name
General Physician Phone Number
Please enter a valid phone number.
General Physician Office Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Specialist Name

First NameLast Name
Specialist Phone Number
Please enter a valid phone number.
Specialist Office Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
When was your child last hospitalized?
What was the reason?
Who provided this application form?
Who was your referral?
Does your child require any special assistance?

YesNo
If yes, please specify
Does your child need or use any of the following

Hearing AidsArtificial LimbsGlasses/Contact LensesOther
If other, please specify
Does your child need or use a wheelchair?

YesSometimesNo
If yes or sometimes, please specify:
What supplies or equipment will be accompanying your child? (e.g. Wheelchair, incontinence pads, bed sheets, dressing pads, nebulizers, physio wedge, etc)

Continence: Is bed-wetting a problem?

YesNo
Does your child have ‘accidents’ during the day?

YesNo
If yes to either of the above, please give details

Consent: I, parent/guardian, hereby give Seaside Travels my permission to use any photographs, film or video taken by them or their sponsors of on their trips for the specific purpose of promoting, advertising or displaying the Trust’s activities. Type Name & Date *This serves as an e-signature*
Consent: I, parent/guardian, hereby give Seaside Travels my permission for them to contact my child’s school to discuss any relevant aspects with regard to his/her participation in a Seaside Travels trip. Type Name & Date *This serves as an e-signature*
Name of School, Telephone number, Teacher’s Name, Principal’s Name
Consent: I, parent/guardian, understand that should my child be withdrawn from a trip for any other reason than a medical or family emergency, any expenses incurred by Seaside Travels relating to my child may be passed on to me. Type Name & Date *This serves as an e-signature*
Consent: I, parent/guardian, understand that my child may not bring a phone or other electronic device on the trip. I also understand that if my child has an injury prior to departure and ends up in a cast or other medical device (moon boot, wrist strapping), I will advise Seaside Travels ASAP. Your child may need to be moved to a future trip as the parks health and safety do not allow patrons on rides with any medical device or material. Type Name & Date *This serves as an e-signature*
I, parent/guardian, hereby consent to the medical/surgical treatment of . I acknowledge that my child has been given my full permission to undertake a trip under the care of Seaside Travels and understand the nature of the trip. I consent to my child receiving full medical treatment of any kind whilst in the care of Seaside Travels and the administering of local or other anesthetics for the purpose of such operation/s. I acknowledge that no assurance has been given that the treatment or operation will be performed by any particular surgeon or pediatrician. Should my child not be current with their vaccinations, I give permission in extreme circumstances, for them to be administered (i.e. tetanus). This consent was read over by myself, the signatory, who acknowledges having understood it fully, and signed in the presence of a witness. I acknowledge that whilst every effort will be made to contact me, in an extreme situation that may not always be possible. Type Name & Date *This serves as an e-signature*
Covid-19 is still present in many parts of the world and busy places where people gather there is a risk of contracting the virus. Do you give permission to test your child and administer medication if needed? Type Name & Date *This serves as an e-signature*
I authorize the release of medical information necessary for participation in non-profit travel events organized by Seaside Travels. I understand that the information provided in this application will be kept confidential and will only be shared with personnel directly involved in the planning and execution of the event. Type Name & Date *This serves as an e-signature*

Checklist:

Please read and ensure that you have done the following

• Answered all the questions
• Completed and signed all consent forms
• Have included latest clinic letter
• Read and understood what you have consented to
• Have included medical forms completed by GP, doctor or Specialist (whoever knows your child best)
Please note that the information you have provided will be used by Seaside Travels only for the purpose of evaluating your child’s suitability for a Seaside Travels trip and to provide information to assist us to care for your child if he/she is accepted. This information will remain strictly confidential.
If you have any queries or concerns while completing this application, please contact us. Please do not send an incomplete application form, as it will be returned for completion, and delays may preclude eligibility for an upcoming trip.
Post the completed form to: hello@seaside-travels.org

List any needs your child require such as medical equipments, specialized care needs, mobility assistance requirements, communication needs, and/or sensory sensitivities
Please explain your child information regarding feeding. Feeding route (e.g., oral, g-tube, j-tube, etc.), if applicable. Feeding schedule, if applicable. Dietary Restrictions or Considerations:
Special Feeding Instructions:
Mobility Equipment Used (e.g., wheelchair, walker, etc.):
Communication Devices Used (e.g., AAC device, communication board, etc.):
Behavioral Considerations or Supports Needed:
Preferred Activities or Interests:
Additional Supportive Equipment Needed (e.g., oxygen, suction machine, etc.):
Any Other Relevant Information:
Declaration: I understand that if any information on this form is false, my child’s application may be revoked. I understand also, that if my child is selected and travels with Seaside Travels, they are to behave as an ambassador for Seaside Travels. Any behavior that jeopardizes the success of the trip may result in the child being sent home early (although only in extreme circumstances). I understand also, that my child’s eligibility for a Seaside Travels trip will also be determined on Seaside Travels attaining full medical/travel insurance and approval to fly from the airline. Type Name & Date *This serves as an e-signature*
Can this child go swimming?

YesNo
Can this child go on rough rollercoaster/motion master type rides?

YesNo
Can this child go on theme park rides (small and sedate)?

YesNo
Please list any injuries, disorders/diseases, and issues if your child have any issues such as Head and Neck (Hx of head injury? Headaches?), Cardiovascular (Hx of heart defects? Arrhythmia? Rheumatic fever?) Eyes, Ears, Nose and Throat (Vision? Conjunctivitis? Hx of middle ear infection? Nose bleeds? Sore throats/thrush?), Respiratory (Hx of respiratory distress? Hx of Asthma? Normal peak flow? Frequent Cough), Gastrointestinal (Hx of GI defects? Diarrhoea/Constipation? Frequent stomach aches? Normal bowel pattern? Laxative/Enema use), Genitourinary (Hx of GU defects? Frequency/Pain/UTI’s? Continent? Nocturnal enuresis? Menses?), Skin (Rashes? Lesions? Hx of scabies/impetigo?), Endocrine (Hx of jaundice/anemia? Bruise easily? Diabetic?), Neurologic (Hx of seizures? Fainting/dizzy spells? Attention span? Development delay?), Musculoskeletal (Hx of injuries/deformities? Co-ordination? Strength? Joint pain/ROM?), or other.
Please comment on Child’s General Condition and Suitability

Declaration: The information given on this form is correct and I have included any reservations I may have regarding the participation of this child on a trip. Type Name & Date *This serves as an e-signature*
Should be Empty: