Media release form

Student Details

Name:
DOB: Do you identify as Indigenous? Yes / No
School:
School email:
Alternative email:
Emergency Phone contact:
Dietary Requirements:

Parental Permission

As parent/caregiver of ……………………………………………………, I ………………………………………...

give my consent for my son/daughter to attend the Geography Field Study

(Please select the appropriate boxes and sign below)

 I understand the photographs, video footage &/or comments recorded during the event may be
used by the organisers and its industry sponsors in media and publications (i.e. websites,
Facebook, media releases, reports, presentations, brochures, etc.)
 I authorise the teachers and staff responsible for the day may take whatever disciplinary action they
deem necessary to ensure the safety, well-being and successful conduct of the students as a
group, or individually, in the abovementioned activity. (N.b. An activity risk assessment for this
activity has been undertaken).
 I also authorise the teachers to obtain medical assistance, which they deem necessary should an
accident occur, and agree to pay all medical expenses incurred on behalf of the above student.
 I further authorise qualified practitioners to administer anaesthetic if such an eventuality arises.
 I submit the following medical information about the above student and include details of limitations,
which he/she has for the activity concerned.

Signed: ………………………………………. (Parent/Caregiver) Date: ………………………..