07 4163 0352
Mt Binga Outdoor Education Centre | 13 Mt Binga Road, Mt Binga 4314, QLD
About Us
Our Mission & Values
Program
Resources
Medical Form
What to Bring
Gallery
Contact
Online Enquiry
Resources
Medical Form
What to Bring
Medical Form
Group Details
School Name
Immanuel Lutheran College
Prince of Peace Lutheran College
Redeemer Lutheran College
Faith Lutheran College Redlands
The Lakes College
Group Number
Group Number
1
2
3
Year Level
Year Level
9
10
Student Details
Student's First Name
Student's Surname
Student's Date of Birth
What gender does your student most associate with?
Student's Residential Address
Emergency Contact Details
Emergency Contact 1
Emergency Contact 1 - Phone Number
Emergency Contact 1 - Alternative Phone Number
Emergency Contact 1 - Email Address
Emergency Contact 1 - Relationship
Emergency Contact 2
Emergency Contact 2 - Phone Number
Emergency Contact 2 - Relationship
Healthcare Details
Medicare Card Number
Medicare Card Reference Number
Medicare Card Expiry Date
Additional Medicare Details
To lodge claims, Medicare requires the Name and Date of Birth for the person listed first on the medicare card. Please provide these details.
Private Health Care Number
Private Health Care Provider
Date of last Tetanus injection
Dietary needs
Does your child have any dietary needs?
Please provide details of your child's dietary needs or leave blank if not applicable
Medical Conditions
Does Your Child Have Any of the Following?
Anaphylaxis/Severe Allergy
Asthma
Auditory Processing Disorder
Autism Spectrum Disorder
Bladder Problems
Bleeding Disorder
Diabetes
Dyslexia
Epilepsy
Fears/Phobias
Hayfever
Hearing Impairment
Heart Condition
Intellectual Impairment
Major Injuries or Operations over the last 12 months
Migraines
Muscular/Skeletal Problems
Physical Impairment
Sight or Hearing Disorder
Speech-Language Impairment
Other conditions that may be aggravated by full participation in the program
None of the above (Please specify below)
Medical Information
Psychological Conditions
Does Your Child Have Any Psychological Conditions?
Mt Binga acknowledges that the information pertaining to psychological and social/emotional conditions is sensitive. Due to the nature of the Mt Binga experience, it is vital that staff are fully informed regarding students psychological needs. The information provided will be treated confidentially and only disclosed to staff members in order to assist them in providing a safe and supportive environment for students.
Yes
No - Please proceed to the next section
Has Your Child Been Diagnosed By A Professional?
(e.g. psychologist, psychiatrist, GP)
Yes
No
Which Of These Conditions Does Your Child Experience?
Anxiety (please specify e.g. generalised anxiety disorder, phobia)
Depression
Suicidal Ideation
Self Harming Behaviours
Eating Disorder
None of the above (Please specify below)
Please Provide Details
Medical Professionals
Treating Professionals
Please provide the name and contact details of any treating professionals
Contacting Medical Professional
Do you give us permission to contact the above listed person/s if the need arises?
Yes
No
Medication
Is Your Child Taking Any Medication?
Yes
No
Medication Details
Paracetamol
I authorise the Mt Binga staff to administer paracetamol as the need arises
Up to 2 tablets at a time
1 tablet at a time
Please call before administering
No
Ibuprofen
I authorise the Mt Binga staff to administer ibuprofen as the need arises
Up to 2 tablets at a time
1 tablet at a time
Please call before administering
No
Antihistamine
I authorise the Mt Binga staff to administer antihistamine as the need arises
As per packet
Please call before administering
No
Additional Details
Any Other Information?
Consent and Authorisation
Animal Program Consent
I understand that Mt Binga Outdoor Education Centre attempts to minimise any risk of personal injury. All activities relating to the horse and animal program including 1) general yard work, and 2) trail riding carry risks that may result in personal injury to the participant, and that accidents may occur. I agree to my child participating in these activities on this understanding.
Yes, I Agree
General Camp Consent
I give permission for my child to take part in the Mt Binga Outdoor Education Experience. I am aware that there are unexpected risks and dangers that cannot be planned for that can occur in outdoor adventures and accepting such risks is an aspect of participation. I authorise staff to carry out medical treatment for my child in the event of an injury or illness and should any costs be incurred as part of treatment that it will be my responsibility. I understand that for the health and safety of all students, staff and volunteers involved in this camp that my child must behave with respect towards all people, equipment and the environment. I understand that if my child should endanger the health and safety of themselves or others that my child may be excluded from activities. I understand that all activities are a challenge by choice and my child may choose not to participate of their own will. To the best of my knowledge, the information given in the above form is true and correct at the time of submission and I understand that this information will be used to support the participant where necessary during the program. If the above information provided changes, or I am to give additional details, I will contact Mt Binga Outdoor Education Centre immediately and provide the amended/additional details.
Yes, I agree to the above terms
Submission Details
Name of person submitting this form and authorising consent
Submit form
