Brandon Park Primary School
Signed Permission
Signed Permission
In the event of an accident or illness, I authorise the teacher in charge of the excursion, to consent , where it is impracticable to communicate with me, to my child receiving such medical or surgical treatment that may be deemed necessary.
Student Name
*
Homegroup
*
Teacher
*
Excursion
*
Excursion Date
*
Excursion Cost
*
Please enter a value between
0.00
and
1000.00
.
Payment method
*
BPay
Cash
Eftpos
Direct Deposit
Date of payment
*
Medical alert
Doctor's name
Doctor's phone number
Medicare number
Private health insurance
*
Yes
No
Private health insurer
Private health insurance membership number
Ambulance Cover
*
Yes
No
Parent/Guardian Name
*
Contact Number
*
Please provide the contact number you can be reached on during this activity.
Alternative emergency contact
*
Alternative emergency contact number
*
Parent/Guardian Signature
*
Email address
*
Please enter your email address. A copy of this form will be sent as a confirmation.
Date of permission
*