THRIV3 Participant Consent Form

THRIV3 Participant Consent Form

Heart first. Always.
This form gives you a short summary of each topic and asks for your consent here. The full details are set out in our policies, linked in each section.

The version that applies to you is the version current on the date you sign. Some sections, such as media and transport, are optional.

You can take part in THRIV3 programs and still say no to these, and saying no will not affect the support you receive.
Participant details
Is this form being completed by a parent, carer or guardian for one or more participants under 18?
Participants under 18
Full name

First NameMiddle NameLast Name
Preferred name
Date of birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone

Area CodePhone Number
Email
example@example.com
Program or activity
THRIV3 site or location
Activity date or dates

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Working with Children Check (WWCC)
Do you have a Working with Children Check (WWCC)?
Working with Children Check (WWCC) number
Expiry

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
If you do not hold a current Working with Children Check, you must not engage with children or young people, unless they are members of your own family, or unless consent or authorisation has been provided by the parent, guardian or a relevant authority.
CULTURAL IDENTITY (optional)
THRIV3 is an Aboriginal Controlled Organisation. Sharing this helps us provide culturally safe support. It is your choice, and choosing not to answer will not affect participation.
Do you identify as Aboriginal or Torres Strait Islander?
ACTIVITIES AND RISK WARNING
Please read this risk warning carefully before you take part.

If you are signing for a person under 18, it is given to you as their parent, carer or guardian and you accept it on their behalf.

RISK WARNING: Many THRIV3 activities, including water-based activities, are recreational activities that involve real risk.

This is a risk warning given under the Civil Liability Act 2002 (NSW). Risks include but are not limited to:
- drowning, near drowning, immersion and cold water;
- slips, trips, falls, cuts, sprains and fractures;
- capsize, entrapment and collision; sunburn, heat, dehydration and weather and ground conditions;
- aggravation of an existing medical condition;
- harm from your own actions or the actions of others.
These risks can result in serious injury, permanent disability or death. Some risks are inherent and cannot be removed even when THRIV3 takes reasonable care. Your participation is voluntary. Nothing in this form removes THRIV3's duty to take reasonable care, and nothing takes away rights under the Australian Consumer Law that cannot be excluded.

Read the full policy:

THRIV3 Risk Management Policy
I have read and understood this risk warning. I understand THRIV3 activities involve risk, that my participation is voluntary, and I choose to take part. If I am signing for a person under 18, I accept this risk warning on their behalf.
Parent, carer or guardian
Parent, carer or guardian name

First NameMiddle NameLast Name
Relationship to participant
Phone

Area CodePhone Number
Email
example@example.com
Emergency contact
Emergency contact name

First NameLast Name
Relationship
Emergency contact phone

Area CodePhone Number
Alternate phone

Area CodePhone Number
Health and medical information
Accurate information helps THRIV3 staff plan, respond, and keep you safe. All information is treated confidentially under the THRIV3 Privacy Policy. For a participant under 18, the parent, carer or guardian completes this section.
Swimming ability and water confidence
Fitness or mobility relevant to this activity
Doctor or clinic name
Contact number
Medicare number
Private health fund
Chronic or ongoing medical conditions
If yes, please give details
Current prescription medications
If yes, please give details
Surgery or medical procedure in past 3 years
If yes, please give details
Allergies including medication allergies
If yes, please give details
Diagnosed mental health condition
If yes, please give details
Seizure or epileptic episode or epilepsy
If yes, please give details
Physical disability or limitation affecting tasks
If yes, please give details
Advised to avoid certain activities or environments for medical reason
If yes, please give details
Dietary requirements
If yes, please give details
Medical conditions and treatment (note to attach management plans such as an Asthma Action Plan, Anaphylaxis Plan, or Diabetes Plan)
Medication to be taken during the activity (name, how and when taken, possible reactions)
Emergency medication storage and administration (name of medication, where stored, who is authorised to assist, expiry checked)
Allergies and special care
Dietary needs
Attach any management plans (optional)

Cancelof
My part in staying safe
Media consent (optional)
THRIV3 sometimes takes photos, video, audio or quotes to share our work. This is your choice and is separate from taking part. Cultural advice: THRIV3 materials may contain images, voices or names of Aboriginal and Torres Strait Islander people who have died. If you tell us someone has passed, we will act with care to remove or restrict that material. You can withdraw consent at any time.

Read the full policy:

THRIV3 Media Consent Policy
Media consent
Privacy
THRIV3 collects personal information, and sometimes health information, to run programs safely, to contact you and your emergency contact, and to meet legal duties.

We handle it under the Australian Privacy Principles and the NSW Health Privacy Principles.

We keep it only as long as needed, then securely destroy or de-identify it. You can ask to see and correct your information, and you can complain to the OAIC or the IPC NSW.

Read the full policy:

THRIV3 Privacy Policy
Health and emergency care consents
Read the full policy:

THRIV3 Privacy Policy
I consent to THRIV3 collecting, using, and storing the health and personal information in this form for the purpose of planning for and supporting the participant's health, safety, and participation, as set out in the Privacy Policy.
I understand the participant will receive appropriate care in an emergency, and I consent to THRIV3 staff arranging first aid and, if reasonably necessary, ambulance or medical treatment. I understand I am responsible for the cost of any ambulance or medical treatment.
Where a medical practitioner has prescribed medication that needs to be taken during the activity, I am responsible for telling THRIV3, keeping the information current, and supplying the correctly labelled medication within its expiry date.
The information I have given is true and complete to the best of my knowledge, and I will tell THRIV3 if anything changes before or during the activity.
Code of Conduct
THRIV3 is a child safe organisation. We expect everyone to act safely and with respect, and to help keep children and young people safe.

Read the full policy:

THRIV3 Code of Conduct
Transport (optional)
Some programs include transport arranged by THRIV3. This is your choice. For a participant under 18, a parent, carer or guardian gives this consent.

Drivers are licensed and screened, and we follow the road rules and child safe practice.

Read the full policy:

THRIV3 Transport Policy
Transport consent
Cancellation and refund (where a fee applies)
Where a fee is charged, our terms are fair, do not include penalty charges, and do not take away your Australian Consumer Law rights.

The more notice you give, the more we can return. If cost is a barrier, talk to us about hardship support.

Read the full policy:

THRIV3 Cancellation and Refund Policy
Related policy
THRIV3 also maintains an Intellectual Property and Cultural IP Policy covering copyright, brand and Indigenous Cultural and Intellectual Property (ICIP).

Read the full policy:

THRIV3 Intellectual Property and Cultural IP Policy
Declaration and signature
I confirm that I have read this form and the summaries in it, that I have had the chance to ask questions, and that my consents and acknowledgements above are given freely.
Participant name
Participant signature
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
I am the parent, carer or guardian of the participant. I have read this form, I accept the risk warning on the participant's behalf, and I give the consents I have ticked above on their behalf.
Parent, carer or guardian name
Parent, carer or guardian signature
THRIV3 (Indigenous Corporation) | ICN: 10165 | ABN: 90 515 247 153

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THRIV3 Participant Consent Form

Participant details

Working with Children Check (WWCC)

CULTURAL IDENTITY (optional)

ACTIVITIES AND RISK WARNING

Parent, carer or guardian

Emergency contact

Health and medical information

My part in staying safe

Media consent (optional)

Privacy

Health and emergency care consents

Code of Conduct

Transport (optional)

Cancellation and refund (where a fee applies)

Related policy

Declaration and signature