13 -14 December 2013, 5pm – 5pm Youth Shak, Gawler Sport & Community Centre (GSCC) Special Notes: Lock in when GSCC closed, canteen & sleep area available

The Town of Gawler cannot collect this information without your consent. The Town of Gawler will supply the information to the Service Providers delivering the LAN Party selected to ensure appropriate emergency medical treatment is supplied if it were required.

Young Persons Details First Name/s: Surname:

Phone Number:

Date of birth: Age (years):

Emergency Contact Details: Please provide details of someone who you would like the Town of Gawler to contact if you were involved in an emergency situation (e.g. accident, sudden illness)

Name:

Relationship: Phone: Mobile: Address:

Guardian/Parent Declaration

• I give permission for ____________________ _________ to participate in the LAN Party dated 13 December 2013.

• I give permission for the Town of Gawler or its Service Providers to provide or obtain medical treatment for him/her should he/she be injured or become unwell (including calling an ambulance)

• I acknowledge that I will be liable for any medical/hospital/ambulance expenses incurred in the treatment of my child

• I understand that the Town of Gawler ensures they and their Service Providers holds appropriate accident and liability insurance and that all due care will be taken to ensure the safety of participants while attending the LAN Party

• I consent for my child to be photographed and for their image and name to be published in circumstances the Town of Gawler deems to be appropriate

• I understand that the Town of Gawler accepts no responsibility for lost or damaged personal items including phones, iPod’s, computers, gaming consoles, etc

• I understand it is not the Town of Gawler’s responsible for the handover of your child/ren at the beginning or end of the LAN Party

I certify that the information entered upon this form is true to the best of my knowledge.

Guardian/Parent signature: ______________________________ Date:

Guardian/Parent Name: ________ _____________________________________

24hr LAN Party Medical & Consent Form If participant is under 18 years of age



Health and Medical Information:

Current Medicare number: Do you have private medical insurance? Y / N Do you have ambulance cover? Y / N Do you have asthma? If yes, please explain the treatment:

Y / N

Do you have diabetes? If yes, please explain the treatment:

Y / N

Do you have epilepsy? If yes, please explain the treatment:

Y / N

Are you allergic to anything? (eg. food or medicine) If yes... What are you allergic to:

What is your reaction:

Y/N

Do you have any mental health concerns? If yes, please explain:

Y / N

Do you have an infectious disease? (e.g. hepatitis, HIV) If yes, please provide detail:

Y / N

Do you take any medication? If yes, please explain what you take and when:

Y / N

Do you have any injuries? If so, please provide further information:

Y / N

Do you have any other medical or health conditions that may affect your participation? If yes, please explain:

Y / N

24hr LAN Party Medical & Consent Form If participant is under 18 years of age