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1. Child 1 name:

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2. Child 2 name:

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3. Parent name: (Required.)

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4. Parent phone number: (Required.)

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5. Emergency contact 1 name:

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6. Emergency contact 1 phone:

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7. Emergency contact 2 name:

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8. Emergency contact 1 phone:

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9. On 30th September, 2026 we will be visiting the Fun Planet Riverside, Shepparton Lake and Rebound during the School Holiday Program to participate in activities, play at the adventure playground at Shepparton Lake and enjoy a session at Rebound. Departure time from Toolamba is 8:15am and we expect to return approximately 3:30pm.
Do you consent for your child/ren listed on this form to attend this excursion?

Note: Please ensure you arrive at 8:00am for a 8:15am departure (Required.)

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10. Jacobson's Mooroopna will be our mode of transport. Seatbelts will be worn where buses are fitted with seatbelts.
Route to and from the destination are available in the risk assessment prepared at the service.
Do you consent for my child to travel by bus to the Fun Planet Kialla, Rebound and Shepparton Lake? (Required.)

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11. Do you consent for the service to seek medical treatment for your child from a medical practitioner, hospital or ambulance, including travel in an ambulance, in the event you cannot be contacted? (Required.)

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12. Do you give permission for educators with current first aid to administer paracetamol in an emergency in the correct dosage for the age of your child/ren?
**Administration of medication will only be given in the event of a parent being un-contactable in consultation with the director or nominated supervisor. (Required.)

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13. Information only - no response required.

We estimate there will be approximately 16 children on this excursion to Fun Planet Riverside, Shepparton Lake and Rebound.

Maximum number of children: 27.
Ratios are maximum of 1:11 as required by ACEQUA and QARD.
A risk assessment has been prepared and is available at the service.

List of educators are below that currently work in the service.

Sarah Maskell

Abby Knight

Emily Keady

OHSC Mobile number 0490 812 401. Please contact this number if you need.

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14. Parent signature: (Required.)

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15. I acknowledge that by entering my name above I am providing a digital signature.

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16. Date:

Date

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