PERMISSION & INDEMNITY FORM - Masada College

ZIONIST / JEWISH STUDIES CAMPS, 2011PERMISSION & INDEMNITY FORMCONFIDENTIAL INFORMATIONTHIS FORM MUST BE COMPLETED, SIGNED BY A PARENT / GUARDIAN AND RETURNEDTO THE JEWISH STUDIES DEPARTMENT NO LATER THAN Friday, 22 July 2011.PLEASE PRINT1. FULL NAME OF CHILD …………………………………………………………………………2. YEAR AT SCHOOL …………………………………………………………………………3. AGE ……………………………………4. HOME ADDRESS ……………………………………………………………………………………………………………………………………………………5. TELEPHONE (HOME) …………………………………………………………………………WORK PHONE - FATHER………………………………………..WORK PHONE - MOTHER………………………………………..MOBILE: FATHER: ……………………………….. MOTHER: ……….……………..………...6. I/We understand that safety is paramount and every care is taken that no accident occurs but, in theevent of any accident, I/we shall not hold the school or any other person liable.7. I/We appoint the teacher-in-charge in loco parentis for my child whilst at camp and, in the event ofan accident and inability to contact me, I agree that decisions regarding any medical care,injections, hospitalisation, etc. may be made by the teacher in consultation with a doctor. I/weagree to pay any accounts so incurred. In the event of serious illness, I/we shall be prepared formy/our child to come home.8. I/We agree that, should my/our child contravene the rules of the camp, the child may be sent homeafter consultation with the Head of School, either at my/our expense or I/we may be required tofetch my/our child.J:\COLLEGE ADMIN\Barel\JEWISH STUDIES\2011\Camps\Year 11\Permission and Indemnity form ZJSC.doc Page 1 of 2

ZIONIST / JEWISH STUDIES CAMPS, 20119. In the event that I/we cannot be contacted personally, please contact the following alternativeperson:i. Emergency contact (daytime) :-(Please PRINT clearly)NAME ………………………….…………… RELATIONSHIP (to child) …..………….TELEPHONE……………………………. MOBILE …………………….………..….ii. Emergency contact (evening) :-NAME ………….…………………………… RELATIONSHIP (to child) …..…………TELEPHONE……………………………. MOBILE ………………………………..10. Date of last Tetanus injection? …………………………………………11. Any special disability, allergy or other matter of which knowledge may be helpful?………………………………………………………………………………………………………..………………………………………………………………………………………………………..………………………………………………………………………………………………………..12. DIETARY REQUIREMENTS ………………………………………………………………………(All food items provided by the College are kosher)13. I/We note that any medication for my/our child must be clearly labelled with:NAME, DOSAGE and FREQUENCYThis is to be given to the teacher-in-charge IMMEDIATELY ON ARRIVAL AT CAMP.14. MEDICARE NUMBER (this is important!) ..……………………………………………………….15. The rules enclosed with this document have been read together with my/our child. All partiesunderstand their content and agree to abide by them.SIGNED ………………………………………………………………… PARENT/GUARDIANFULL NAME – PARENT/GUARDIAN (Please print) …………………………………………….DATE: ……..…………………………J:\COLLEGE ADMIN\Barel\JEWISH STUDIES\2011\Camps\Year 11\Permission and Indemnity form ZJSC.doc Page 2 of 2