Hillary Outdoors Medical and Consent Form
Hillary Outdoors Education Centre - Tongariro
PARTICIPANT DETAILS
First and Last Names *
Your answer
Participant's Gender *
Age *
Your answer
Date of Birth *
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Phone 1 *
Your answer
Address
Your answer
Participant's Email
Your answer
Please tick the box if you do NOT want to receive information about other courses at Hillary Outdoors. At no time will we ever sell or provide your information to anyone else.
NEXT OF KIN / EMERGENCY CONTACT
Next of Kin Name *
Your answer
Relationship to participant *
Your answer
Phone 1 *
Your answer
Phone 2
Your answer
Phone 3
Your answer
Email
Your answer
PERSONAL INFORMATION
Hillary Outdoors has a policy of inclusion. In order to achieve this safely it is vital that we have as much information as possible about our participants. It is ESSENTIAL that you give us accurate and detailed information. Note: Any information provided will be treated as confidential.

IF ANYTHING CHANGES BETWEEN COMPLETING THIS FORM AND THE TRIP IT IS ESSENTIAL YOU LET US KNOW.

Do you have dietary needs? *
Dietary details (if required)
Your answer
Do you have medical conditions? E.g. injuries, allergies, anxiety, diabetes, obesity, behavioral, addiction, sight or hearing impediments or other. *
If yes, please give details of medical condition.
Your answer
Are you taking any medication? *
If yes, please give details of medication e.g. epipen, inhaler, antihistamine etc
Your answer
I agree to me/my child being given over the counter medication e.g. Panadol or ibuprofen *
SWIMMING ABILITY INFORMATION
Are you able to swim 50 metres *
Are you confident in moving water? This includes rivers, lakes and deep water. *
SNOWDAY INFORMATION
Your school may opt for a Snowday on Whakapapa Skifield, if so we need the following information to pass on to the Rentals Department:
Height (cm) *
Your answer
Weight (kg) *
Your answer
Foot size - see: https://bit.ly/2GZCCkd e.g. Youth 9 Quest
Your answer
Which activity would you like to participate in? (in some cases your school may choose for everyone - your school will let you know if this is the case) *
What level are you at? *
CONSENT
Detailed information about our safety system and activities is provided at www.hillaryoutdoors.co.nz/safety/

IN SUMMARY:
- Hillary Outdoors offers a wide range of activities which may include: kayaking, canoeing, tubing, river walking, rafting, rock-climbing, ropes courses, abseiling, camping, tramping, caving, skiing, snowboarding, and snow skills.
- Participation in all activities at Hillary Outdoors is voluntary although students are supported and encouraged by their peers and instructor to participate to a level which challenges them.
- Because of the changeable and unpredictable nature of the outdoors risks can never be reduced to zero. Hazards exist in these activities that may result in serious injury or even death. These hazards include: weather / environmental conditions, height, water, equipment, client specific hazards, environmental impact and vehicles.
- Our goal is that no harm will occur whilst involved in activities. Our management strategies for achieving this can be viewed online.

PLEASE CONTACT US IF YOU REQUIRE MORE INFORMATION TO MAKE A DECISION, OR IF YOU HAVE ANY QUESTIONS

Please read each statement and then indicate your consent below.
- I understand there are risks associated with outdoor activities that cannot be reduced to zero. I know I am able to ask any questions of Hillary Outdoors or the individual instructor to gain a better understanding of the activity before deciding whether to take part, and the final decision about whether to take part or not is mine. If I decide to take part, I understand the instructor will identify any hazards that are liable to arise and correct procedures to deal with these, and that it is necessary for me to follow these. The instructor will take all reasonable precautions to ensure my safety. If I act outside of this advice, then I acknowledge I do so at my own risk and may be instructed to leave the programme or activity.

- I have received enough information to make an informed decision about the programme I am / my child is about to undertake.

- I authorise Hillary Outdoors to instigate medical assistance and treatment required in an emergency.

- I understand I may be charged for items belonging to Hillary Outdoors I lose or damage.

- I understand that my personal effects are not covered by Hillary Outdoors insurance policy.

- I understand that if I am under the influence of alcohol, drugs or other substances, Hillary Outdoors has the right to stop my further participation on the programme and I have no right for refund of my course fee.

- I have read the information sent to me and agree to act within Hillary Outdoors' policies and expectations. I understand that Hillary Outdoors cannot be responsible for storage or administration of my child’s medication, unless specifically requested to do so prior to their visit.

- I understand Hillary Outdoors Tongariro operates in an area with active volcanoes with associated risks. For
further information please see:
https://www.doc.govt.nz/parks-and-recreation/places-to-go/central-north-island/places/tongariro-national-park/

PLEASE CONTACT US IF YOU REQUIRE MORE INFORMATION TO MAKE A DECISION, OR IF YOU HAVE ANY QUESTIONS

I, the participant, AND the parent/guardian agree with ALL of the above. *
We require all participants to complete this form and parent/guardians to confirm their permission for their child to participate if they are under the age of 18. Photos and videos of participants to our courses and programmes may occasionally be used for marketing purposes. We assume your permission to any of you / your child unless otherwise requested by you.

By completing your name and the date below you are confirming that the information provided is as accurate and as complete as possible and you are confirming that your / your child's participation is in the stated Hillary Outdoors programme.

Parent / Guardian's Name *
Your answer
Today's Date *
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Participant's Name *
Your answer
Today's Date *
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