Activity Permission form Mansfield Autism Statewide Services promotes health, wellbeing and time spent in nature. Our service is built on exercise, healthy eating and sleep routines. As part of our program we take students on activities and excursions to explore nature. All activities and excursions are carefully supervised in line with our supervision policy and we always complete a risk assessment before any excursion to be aware of and manage any risks. This form seeks permission for the student to participate in activities and excursions.Student name(Required)Permissions Please tell us which of the following excursions and activities you give permission for your child to participate in while in the care of Mansfield Autism Statewide Services:On Campus activities Yes to all on campus activities Swimming(Required) YES NO Bike riding(Required) YES NO Local Mansfield activities Yes to all local Mansfield activities Bush walking(Required) YES NO Snow play and tobogganing(Required) YES NO Playgrounds(Required) YES NO Mansfield Zoo(Required) YES NO Community trips Yes to all community trips Visits to nearby towns(Required) YES NO Skill Level How well can your child do the following activities:Ride a bike(Required) Very well Need some support Need lots of support Not well at all Swim(Required) Very well Need some support Need lots of support Not well at all Cross the road(Required) Very well Need some support Need lots of support Not well at all Walk with a group(Required) Very well Need some support Need lots of support Not well at all Be out in the community (shops etc)(Required) Very well Need some support Need lots of support Not well at all Acknowledgement(Required) I acknowledge the nature of these activities and realise the potential dangers involved in my child’s participation. Consent Where staff in charge of the excursion are unable to contact me, or it is otherwise impractical to contact me, I authorise the staff member in charge to:Receive medical Consent to my child receiving any medical or surgical attention deemed necessary by a medical practitioner Administer first-aid Administer such first-aid as the staff member in charge judges to be reasonably necessar Signature Parent / Guardian name(Required)Date(Required) DD slash MM slash YYYY Signature(Required)
