Medical Form

Group Details

Group Number
Year Level

Student Details

Emergency Contact Details

Healthcare 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.

Dietary needs

Please provide details of your child's dietary needs or leave blank if not applicable

Medical Conditions

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.
(e.g. psychologist, psychiatrist, GP)

Medical Professionals

Please provide the name and contact details of any treating professionals
Do you give us permission to contact the above listed person/s if the need arises?


I authorise the Mt Binga staff to administer paracetamol as the need arises
I authorise the Mt Binga staff to administer ibuprofen as the need arises
I authorise the Mt Binga staff to administer antihistamine as the need arises

Additional Details

Consent and Authorisation

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.
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.
Name of person submitting this form and authorising consent