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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 Thursday 1st October, 2026 we will be visiting Aquamoves, Shepparton Lake and Village Cinemas during the School Holiday Program to participate inswimming, watch a movie at Village Cinemas (popcorn, drink and treat.) Departure time from Toolamba is 8:30am 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 8:15am for a 8:30am departure (Required.)

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10. Fords Shepparton 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 Aquamoves, Shepparton Lake and Village Cinemas Shepparton? (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 20 children on this excursion to Rebound and Village Cinemas Shepparton.

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

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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