Permission for student to attend
excursion – parent consent form
Questions are followed by answer fields. Use the ‘Tab’ key to navigate through. Replace Y/N or Yes/No fields wit h your answer.
Excursion details - to be completed by school
School name Nemarluk School
Teacher in charge Carmine Adamo Class/Year/Subject TR to Yr 5
Rebecca Gibson -Health and
Jo Lasham Physical
Education
Gabby Woodward
Likely number of children participating 8
Likely number of staff participating 3
Anticipated ratio of educators to children 1:3 approx
A risk assessment has been prepared for this excursion and is available upon request.
Purpose of the excursion
To provide students opportunities to participate in a variety of sports in a fun and in an inclusive
environment. The excursion will also encourage students to explore sporting opportunities in their local
community to participate in.
Details of the destination
Netball Northern Territory
235 Abala Rd, Marrara NT 0812
Opens 8:30am and Closes 4:00pm
Times and dates of the excursion
From date 15/09/2021 Time 10:00am
To date 15/09/2021 Time 1:00pm
Regular outing / reoccurring excursion details - if applicable
Date/s Time/s
Day/s of outing How often will the
outing occur e.g. weekly
for 6 weeks
Department of EDUCATION
6 April 2021 | Version 1.0
Page 1 of 6
Permission for student to attend excursion – parent consent form
Details of each activity
Students are attending Activate Inclusion Sports Day which is an inclusive day of sports. Students will rotate with
class around the Netball NT venue participating in a variety of sports run by a specified coach of that sport.
Students will develop their Fundamental Movement Skills in a variety of movement sequences and situations. Also,
students will learn to cooperate with others when participating in the different sports and also practise personal
and social skills to interact positively with others.
Student requirements: e.g. sun protection, running shoes
Nemarluk School uniform, running shoes, recess and lunch, drink bottle.
Accompanying adults
Name Position Name Position
Rebecca Gibson Classroom Teacher Carmine Adamo Physical Education
Teacher
Joanne Lasham SESO Gabby Woodward SESO
Planned transport School bus/Hire bus/Town bus/Staff or parent vehicle/Student’s own
vehicle/Walking/Other
Costs associated with the excursion
Excursion costs - $ NA Suggested spending money - $ NA
Teacher in charge Carmine Adamo Form return date 13/09/2021
Teacher in charge Date 07/09/2021
signature
C. Adamo
Principal signature Date
Department of EDUCATION
6 April 2021 | Version 2.0
Page 2 of 6
Permission for student to attend excursion – parent consent form
Student details - to be completed by parent
Please complete all details below and return to the Teacher in Charge by the return date. Failure to do so
may result in your child being unable to participate in the activity.
Student’s family name Student’s given name
Student’s date of birth Student’s gender Male/Female
Contact details
Parent’s name Emergency contact
Preferred contact Work/Home/Mobile Preferred contact Work/Home/Mobile
Work Work
Home Home
Mobile Mobile
Student’s medical details
Known allergies e.g. drug reactions
Dietary restrictions
Date of last tetanus injection
Is the student under medication? Yes/No
If yes, name medication and attach instructions
Has your child any special medical condition, Yes/No
physical or psychological limitations or cultural
restrictions which may affect her/him whilst
taking part in any activities?
If yes, please provide full details, attach
information if necessary. Please provide any other
information which you believe may help staff
provide the best possible care.
Department of EDUCATION
6 April 2021 | Version 2.0
Page 3 of 6
Permission for student to attend excursion – parent consent form
Parental consent
Your attention is drawn to the following important points:
• Students are under the teacher’s/supervisor’s authority for the duration of the excursion. A
student may be returned home at the expense of the parent/caregiver if the teacher/supervisor
considers that circumstances warrant such action.
• The Department of Education has a duty of care for students engaged in school related activities,
including excursions and sporting events under its direction or supervision. All reasonable steps
will be taken to protect students against reasonably foreseeable risks of injury or harm.
• Financial responsibility for medical and other costs incurred in emergency situations or where a
decision is taken to return a student home, rests with the parent/guardian of the student. Parents
may wish to take out additional insurance to cover such costs.
• Liability for loss, theft or damage to student property is the responsibility of the parent/guardian
of the student.
• Students are not permitted to transport other students in vehicles regardless of written
permission being provided.
• The parent/guardian is responsible for informing the school/preschool of any change in consent
to their child attending an excursion and of any changes to student medical details.
Privacy Notice: The Department of Education collects the information on this form in accordance
with the Excursions Policy, and may disclose this information to third parties in connection with
this excursion. Failure to provide this information may result in your child being unable to attend
the relevant school excursion. For further information, or to access the information you provide
on this form please contact your child's school.
Permission is given to attend this excursion Yes/No
Permission is given for school staff to administer Yes/No
first aid if required
Permission is given to secure medical attention in Yes/No
case of illness/accident whilst on this excursion
and I accept responsibility for any costs involved
including ambulance transport if applicable.
I agree to pay the excursion costs outlined above Yes/No
Is your child under the age of 7? Yes/No
If yes, complete Child restraints form.
Does the excursion involve aquatic activities? Yes/No
If yes, complete Student’s swimming ability form.
Parent’s name Date
Parent’s signature
End of form
Department of EDUCATION
6 April 2021 | Version 2.0
Page 4 of 6
Permission for student to attend excursion – parent consent form
Child restraints form
Seatbelt and safety restraint requirements are dependent on the type of vehicle being used. In the NT all
children under seven years of age must be secured in an approved child restraint or booster seat when
travelling in a vehicle. For further information see Child restraints frequently asked questions.
Is a child Yes/No
restraint/booster seat
requested?
If yes, an approved School/preschool/parent/guardian
child restraint/booster
seat will be provided by
the
If required, I agree to Yes/No
provide an approved
child restraint/booster
seat
Parent’s name Date
Parent’s signature
Department of EDUCATION
6 April 2021 | Version 2.0
Page 5 of 6
Permission for student to attend excursion – parent consent form
Student’s swimming ability form
In relation to the proposed swimming activity in my opinion, my child is:
A non-swimmer: my child is unable to swim Yes/No
A weak swimmer: my child is comfortable and Yes/No
confident in shallow water but is not very strong
or confident in deep water. My child cannot swim
more than 10 meters
An average swimmer: my child is a reasonable Yes/No
swimmer and can swim 25 metres and is confident
in deep water
A strong swimmer: my child is a strong swimmer Yes/No
and can swim more than 50 metres and is
confident in deep water
My child is permitted to go in the water Yes/No
What level has the student achieved in the RLSSA
Swim and Survive Program?
If known provide the date it was achieved
I consent to my child swimming with supervision Yes/No
In addition to parental assessment of a student’s swimming ability, assessment of an individual’s
swimming proficiency is conducted by the school/teacher before participating in any aquatic program or
activity.
Parent’s name Date
Parent’s signature
Department of EDUCATION
6 April 2021 | Version 2.0
Page 6 of 6
