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Siblings Program - Registration and Consent Form

(for children aged 5-12)

Registration Enquiry form

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Participant details
Emergency contacts
SIBS Participant(s)
Medication Agreement - CONFIDENTIAL
Consent & Authority

Participant details

Children
Parent/Guardian Name(s)
Parent/Guardian 1
Parent/Guardian 2

Emergency contacts

Emergency contacts
Enter in order of priority. Minimum 2 emergency contacts.

SIBS Participant(s)

Does your child require medication to be taken during the program? 
If you select yes, you will be asked to complete a medical form as part of your registration to the program.
Please specify and indicate any preventative measures or treatment that you have in place for this condition.
(please indicate)

Medication Agreement - CONFIDENTIAL

This information is confidential and will be available only to relevant Childhood Cancer Association staff and emergency medical personnel. The legal guardian can complete the medication agreement authorising the taking of medicine whilst attending a group program. All sections of the Authorisation must be completed. Childhood Cancer Association staff are not responsible for the administration of medication, except in the case of an emergency.

Medication instructions

The medication instructions must match EXACTLY the pharmacy label on the medication or medication will not be administered.

(liquid, tablet, capsule, lotion, inhaler, injection)
(skin, oral, inhaled)
(mg or mg/ml)
(the number of tablets or mls must be written)
To be administered within 1⁄2 hour of specified time(s)
(Medication Agreement ceases to be valid as at this date)

Authorisation and Release

The medication documented above is required to be administered during attendance at the SIBS program.
Where the medication is a prescription medication; the medication has been prescribed for a current health condition.
I confirm this medication has been administered to my child previously (a first dose cannot be administered in this setting) 
I confirm that my child is able to self-administer this medication.
My child is well enough to attend the program and if there is a change in my child’s health condition I will be called to collect them. 
I understand the medication provided must have a pharmacy label that matches the information in the Medication Agreement or the medication will not be administered. 
I approve the release of this information to supervising staff and emergency personnel (if required). 
I understand and agree to the supervising staff not be administering the medication, except in the case of an emergency. 
I confirm I have provided staff with any medical/health management plans (i.e. anaphylaxis plan) 
I authorise the medication as instructed above to be administered in the setting. 
I certify the above statements are true and correct. 

Consent & Authority

Media Consent 
This media may be used for the Childhood Cancer Association Newsletter and promotional material, digital media and/or other traditional media purposes.
Please note: It may also be used by special guest visitors or venues we may visit during their program for their own promotional material, digital media and/or other traditional media purposes
Please specify if there are any restrictions e.g. do not want a photo to appear on Facebook, etc.

Authority

In signing this form I agree to the terms and conditions and give consent for my child/children to attend the SIBS program. This involves activities at varying locations around Adelaide and which are sometimes conducted by external organisations/professionals. In signing this form, I agree to the following:

  • If my son/daughter breaks certain program rules, then he/she may be sent home immediately.
  • If I RSVP for my child to attend an event, but my child is unable to attend closer to the time, I will notify the Childhood Cancer Association as early as possible, or else I might be responsible for any costs incurred by the Childhood Cancer Association that have resulted from my child/ren not attending the session. This may include a cancellation fee of $50 per child per session.
  • I give the Childhood Cancer Association staff and volunteers consent in the event of any accident or illness to obtain such medical assistance as is required and I agree to meet any costs involved therein (e.g. transport via ambulance to a medical facility). Should this be necessary, I understand that I will be notified as soon as possible.
  • I agree to let the Childhood Cancer Association know if my son/daughter(s) have been in contact with or has any contagious illnesses (e.g. measles, chicken pox, shingles) in the two weeks prior to the program.
  • I agree that my child won't attend a session if they have been a close COVID-19 contact.
  • If my child is unwell on the day of the program, I agree to exclude them from the program.
  • I acknowledge and agree that the Childhood Cancer Association is not liable, and excludes all liability, for any damage, loss, harm, injury, cost or any other liability or expense of any kind arising from, or in connection with, any act or omission, whether caused by negligence or otherwise, of the Childhood Cancer Association or any members of its staff or volunteers during the program.
  • Some activities may involve an increased risk for participants (e.g. bouncing/climbing apparatus, water sports, cooking). While the Childhood Cancer Association does everything in its power to minimise risk and to keep participants safe, the Childhood Cancer Association is not liable, and excludes all liability, for any damage, loss, harm, injury, cost or any other liability or expense of any kind arising from individual participation in these activities.
Parent/guardian name