Protect yourself online. Learn more...
Quick Exit

Quick Exit

Protect yourself online. Learn more...

Adventure Works Health and Mental Health Form

Privacy

How we store your information

Adventure Works Pty. Ltd. collect your personal information for the purpose of ensuring that we can provide safe and effective services for you and other participants. We store your information (data) on server's located overseas and hosted by a third party 'CiviHositng' who specialise in hosting servers for NGO's and community organisations. CiviHosting and their support contractor will only access our data stored on their server by specific request from us, or if they are required to by law. Our server is secured using up to date security practices and our server host has an excellent track record for maintaining the integrity of client data. Having said all this, online storage, like any storage of data is not foolproof. While we take the utmost care with the details you provide, we cannot guarantee 100% that it will remain under our explicit control in all circumstances.

How we share your information

Adventure Works Pty. Ltd. staff will share your information with each other as needed, so that we can provide the most appropriate support to you throughout the time that you are involved. We will not share your information amongst staff needlessly.

Adventure Works Pty. Ltd. staff will not share your information with third parties without your express permission unless: a) we are required to by law; b) it is in an emergency situation and the information is relevant to providing you with immediate care; c) we become aware that you are placing yourself or others at risk of harm.

Privacy Agreement

By checking this box and continuing to fill in this online form, you are confirming that you understand that your information will be stored online and on a server located overseas, and, that you accept the risks both known and unforeseen that this poses.


Contact details

In this section we will collect your basic contact information.

   

Key contacts

In this section we will collect information about a few key contacts who we might get in touch with throughout your involvement with us.  During the application process we like to get in touch with at least one personal referee, a family member of friend who knows you well; and one professional referee, a support worker or doctor who would also know you well. We do this because when we go away together, we are often in new groups, we are sometimes in more remote areas and we need to have some idea about your readiness and your health and wellbeing so we can plan and make sure there is nothing that will get in the way of participating fully. We also need to get your next of kin contact details, this is a person who we would get in contact with in the event that something happened while we were away with you.

Please add details as follows: name - relationship to you - phone contact number,
e.g. Jane Smith - Mother - (03) 1234 5678

Please add details as follows: name - relationship to you - phone contact number,
e.g. Susan Smith - Friend - (03) 1234 5678

Please add details as follows: name - relationship to you - organisation - phone contact number,
e.g. Dr Jennifer Smith - General Practitioner - ABC Health Services - (03) 1234 5678

Please add details as follows: agency/ organisation - contact person - phone contact number,
e.g. ABC Support Services - Justine Smith - (03) 1234 5678


Health information

This section will collect remaining health related information that we require to safely go with you out into the bush and and into remote areas.

Please enter your medicare card number here.

If applicable, please enter your health care card number here.

Please include any dietary considerations that you might have here so that we can cater for your needs.

Please include any special assistance needs you have here so that we can take them into account while planning.


Assumption of risk

Please mark the check box below if you have read and agree to this statement. If you are under 18, please download a PDF version and have a parent/guardian co-sign it with you:

  • Risk - I understand that adventures involve risk, and that AW events involve some risks.
  • Safety - I am willing to participate safely and responsibly.
  • Medical event - I understand that if an accident or illness occurs and if it is impossible to communicate with me or my parent/guardian, that the facilitator will arrange medical or surgical treatment seen as necessary.

Media consent

I acknowledge that media including photographs, audio and video recordings may be taken during AW activities on behalf of AW. I understand that by selecting 'yes' here, I am agreeing to allow AW to produce and store media of me and that such media may be used in print or electronic publications, for promotional purposes or for purposes related to the activities, programs and services of AW. Specifically for audio or video recording, prior to publishing, AW will discuss with you how and why we might wish to use this material and gain additional verbal consent. We are committed to ensuring that any use of media is respectful to all involved.

If you select 'no' here, it will not effect your participation in AW events in any way. It is not a requirement for you to select 'yes' to participate and it will in no way prejudice our selection of you in any group. In the event that you select 'no' here, there may be occasions where you accidentally appear in group photo's, however, staff who are producing any publishable media will vet and make sure that no media including you are made public.


Once you have completed all the parts of this form that you can, press save below to submit your form. Once submitted, if you provided an email address, an email will be sent to you to confirm that you have filled it in and for your records. If you need to add any more details, you can do this either by calling the contact person for the activity you are participating in or email us at .



Part A

Brief Medical History: Do you suffer from any of the following? Please select and add comments. If you add details at a later time, please date each new entry. If you plan to attend an overnight camp please provide additional information in Part B of this form.Using a new line for each medication you are currently on, please detail: What medication you are taking, What it is for, The dose you take, How often you take it, Time of day medication is taken. For example, 'Seretide, Asthma, Preventer, 4 puffs, taken every morning after breakfast'

Part B

AW OVERNIGHT Additional Medical Information: If you suffer from any of the following, answer the relevant questions and provide additional medical information below. Please attach management plans if available.
Too much paperwork? If you’d prefer, we can speak with you on the phone.If you have any allergies, please answer the following allergy related questionsIf you suffer from asthma, please complete the following asthma related questionsIf you suffer from diabetes, please answer the following diabetes related questionsIf you have dizzy spells, epilepsy or seizures, please answer the following:Additional conditions – please complete a Condition Overview for each of the following conditions. Please contact us if you need additional pages, and provide management plans if you have them. Additional conditions may include Back or Joint Injuries, Communicable Disease, Heart, Lung or Kidney Problems, Mental Health Issue/s (including alcohol or other drug dependency) and any other conditions that may affect your participation.