FORM E1 (JUL 18)

PLEASE RETURN ACTIVITY NOTIFICATION FORM

COMPLETED FORM TO THE PART I - ACTIVITY PARTICIPATION AND MEDICAL FORM
ACTIVITY COORDINATOR (This page is to be completed and returned for All Participants)

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ACTIVITY DETAILS - (FOR FULL DETAILS PLEASE SEE PAGE 2)
ACTIVITY: Terry Hills to Peach Trees Fire Trail ride ACTIVITY NO:
GROUP/FORMATION: 2nd St Ives Scout Group
LOCATION: meet at Echunga Rd Duffys Forest adjacent to the Northern Beaches Christian School
START TIME (24hr): 0900 DATE: 19/05/2024 FROM:
FINISH TIME (24hr): 1100 DATE: 19/05/2024 TO:
Name of Activity Coordinator: David Kinchington Phone: 0418266486
Cost: free Payable to: Closing Date:
Method of transport to and from the activity: Own transport
PARTICIPANT DETAILS - TO BE COMPLETED BY ALL PARTICIPANTS OR PARENT/GUARDIAN IF UNDER 18 YEARS
GROUP/FORMATION: 2nd St Ives Scout Group MEMBERSHIP NO.
SECTION: Joey Scout Cub Scout ✔ Scout Venturer Rover Leader Helper / Instructor / Non Member
SURNAME: GIVEN NAMES:
ADDRESS:
TOWN/CITY: STATE: POST CODE:
TELEPHONE: MOBILE: E-MAIL:
DATE OF BIRTH: GENDER: Male Female RELIGION/FAITH:
(Optional)
Friday Saturday Sunday Days Only
ATTENDANCE: ALL
✔ Friday Night Saturday Night Sunday Night Other

In case of Emergency contact: Phone:

Address: Suburb: Mobile:

If the participant suffers from any condition, ailment, allergy or disability that could affect their participation in the activity, it should be disclosed
so provision can be made for their welfare and participation. Further details can be given on the back of this form. Please attach any Medical Plans that apply.
Does the participant have any conditions or disabilities that could affect their Does the participant suffer from any of the following?
participation?
Yes Details: Epilepsy: Yes Level: Mild Severe

Does the participant have any known allergies, including drugs or food allergies? (i.e. Diabetes: Yes Level: Mild Severe
Penicillin, Egg, Peanut Products, Bee Stings, Hay Fever, other drug or food allergies):
Yes Details: Asthma: Yes Level: Mild Severe

Has the participant any special food requirements? (for Medical, Religious) Will the participant have any medication at the activity?
(i.e. Penicillin, Insulin or other Drugs administered by Injection, Tablet, Capsules,
Yes Details: EpiPens or other).
Yes Name of Drug:
Dosage: How Often:

Date of last Tetanus Injection: or unknown Administered by: self or whom:

PARENT CONSENT - TO BE COMPLETED BY PARENT/GUARDIAN FOR PARTICIPANTS UNDER 18 YEARS

Can the participant Swim 50 meters? Yes
I consent to my childs participation in the following which may be a part of this Activity.
Swimming Water/Boating Activities Rock Related Activities Abseiling Flying Fox Flying

MEDICAL AUTHORITY - TO BE COMPLETED BY ALL PARTICIPANTS OR PARENT/GUARDIAN IF UNDER 18 YEARS

I/We acknowledge that this activity will involve inherent and obvious risks. I/We authorise any officer, member, servant or agent of The Scout Association of Australia, New South
Wales Branch, in the event of any accident or illness to obtain such urgent medical assistance or treatment for the above named participant, including the administration of any
anaesthetic or blood transfusion as he or she may consider expedient and for this purpose to engage any first aiders, ambulance officers, doctors, dentists, nursing assistance or
hospital accommodation and in this event I agree to pay the said Association on demand all such doctors', dentists', nurses', ambulance and hospital fees (other than fees and
expenses recoverable by the said Association under any policy of insurance).
If you have any questions please contact: Phone

Participant:
Parent/Guardian
(If Participant Under 18 Years)
Signature Print Name Date

FORM E1 - Part I ....1/4

 Scouts Australia NSW FORM E1 (JUL 18)
Level 1, Quad 3
102 Bennelong Parkway
Sydney Olympic Park NSW 2127
ACTIVITY NOTIFICATION FORM
PO Box 125 PART II - PARTICIPANTS & PARENTS ADVICE
Lidcombe NSW 1825 (This page is to be kept by participants)

Ph: (02) 9735-9000 Fax: (02) 9735-9001

Email: [email protected]

ACTIVITY DETAILS
ACTIVITY: Fire trail riding at Duffys Forest ACTIVITY NO:

GROUP/FORMATION: 2nd St Ives

LOCATION: meet at Echunga Rd Duffys Forest near the Northern Beaches Christian School

START TIME (24hr): 0900 DATE: 19/05/2024 FROM

FINISH TIME (24hr): 1100 DATE: 19/05/2024 TO

Name of Activity Coordinator: Phone:

Cost: $25 Payable to: Climbfit Closing Date:

Method of transport to and from activity: Transport by carer/parent

The activity ✔ will will not be under direct adult supervision.

The activity ✔ will will not involve both male and female youth members.

Both male and female Leaders will ✔ will not be present

EMERGENCY CONTACT
If you feel that the participant is overdue in returning from the activity you should contact the nominated emergency contact.

Name: David Kinchington Home Phone: Mobile: 0418266486

ADDITIONAL DETAILS
Provide details about the activity. Can include gear lists, map references etc.
This is the start of our preparation for Bike Hike. If you don't have a bike speak to Chil.

Today we will be riding along a firetrail from Terry Hills ?Duffys Forest to Peach Trees and back.

You need to bring a bike with functioning gears and brakes, helmet, clothes suitable for riding a bike, small backpack/daypack for snacks
and water.

FORM E1 - Part II ....2/4