Practical Experience Register HLPE 3532

Student: _Emmie Delchau ____________________________________________________

Student Id: __2119137_________________________________________________
Use numbers to indicate your preference. (1=first preference, 2= next preference, etc)
Please place a number in all the boxes provided. All efforts will be made to give you your first preference, but logistics may prevent
doing so in some cases.

Equipment Tutorial Paddy Pallins 5.30-7.30pm (Compulsory) choose 1 of 2

Thurs 13th August 1
Thurs 20th August 2

Mountain biking (optional) Woodcroft College 2.00pm

Wed 9th Sept (TBC) 1
Fri 11th Sept (TBC) 2

Day walk August (Compulsory) choose 1 of 2

Mon 10th August 2
Tues 18th August 1

Expedition (Compulsory) Deep Creek C.P.

21st to 23rd September

Sept First Aid Course TBA September including BELS (optional)

Optional (self-directed)

Introduction to Rock-climbing Sept (optional) COST $30 choose 1 of 2

Mon 31st August 2
Tues 1st September 1

Quest Options Grampians Victoria

#1, 10 23 October 2
#2, 24 October - 6 November 3
#3, 7 - 20 November 1

FLINDERS UNIVERSITY - PHYSICAL EDUCATION STUDIES

OUTDOOR EDUCATION STUDENT CONSENT FORM

(PLEASE WRITE ALL INFORMATION CLEARLY & LEGIABLY PARTICULARLY EMERGENCY CONTACT NUMBERS)
The information requested on the student consent form and health information sheets will be considered confidential by the University and
will be treated accordingly. The information is sought in order to protect and assist the student so that the activity may be a safe and
enjoyable experience. Please attach extra sheets if required and contact the Topic Coordinator to discuss any student health problems.
Any information given will not prevent students from taking part in outdoor education activities unless further medical advice warrants
exclusion.
CONSENT:
I agree to delegate authority to the Outdoor Education staff and instructors and to take whatever action they deem necessary to ensure the
safety, well-being and successful conduct of the students as a group, or individually in any of the activities associated with this topic;
realising that there are degrees of risk of personal injury associated with most outdoor activities.
I also authorise the staff and instructors to obtain medical assistance which they deem necessary should an accident occur and agree to
pay all medical and dental expenses incurred.
I have attached the health information sheet and include details of limitations which I have for the activities concerned. I further legally
authorise qualified medical practitioners to administer an anaesthetic or carry out necessary surgical procedures if such an eventuality
arises. I give my consent for my local doctor or medical specialist to be contacted in an emergency.
The information given is accurate to the best of my knowledge.
Date: __24/07/15__________ Signed: ______Emmie Delchau_________________ Contact No: _0433905527____________
Student
EMERGENCY CONTACTS:

PARENT OR GUARDIAN
Aaron Delchau (husband)
Address
9 Ramsay Ave Reynella East 5161

0400818855
Home Telephone No.

Alternative No.

Home Telephone No.

Work Telephone No.

Alternative No.

Home Telephone No.

Work Telephone No.

Alternative No.

FAMILY DOCTOR OR MEDICAL CLINIC

Drs on South
Address
South Rd Morphett Vale

Work Telephone No.

83847774

MEDICAL SPECIALIST (if relevant)

Address

OTHER INFORMATION:

Can you confidently swim 100m?

Y / N ; If Y evidence of capacity:

Passed Flinders University S&W/S Survival Swim test? . Y / N, or

Other evidence

Do you have dietary requirements? Y / N

If yes, what are they ?:__No Gluten, Dairy or Red Meat________________________________________

List any sport, recreation or outdoor education qualifications and/or skills you have:
___________________________________________________________________________
2

FLINDERS UNIVERSITY - PHYSICAL EDUCATION STUDIES

GIVEN NAMES:

Emmie

SURNAME: Delchau
STUDENT HEALTH INFORMATION

MEDICAL CONDITIONS
Does the student have any medical conditions or health problems?
If you have answered YES, please provide details:

YES

NO

[x ]

DETAILS:

Are you aware of any medical emergency which could occur?

If you have answered YES, please give details:

YES

NO

[ x ]

Precautions to avoid
emergency
How to recognise
emergency
Emergency treatment
required

MEDICATION
Does the student take any prescribed medication (including inhalers)?
If you have answered YES, please give details:
Medication Name

Dose

When taken

YES
How taken

Any side effects

Has the student received a complete course of Tetanus Toxoid

immunisation?
YES
[ x ]
NO
[ ]
Check details with you doctor if uncertain. Date of last booster .............

MEDICARE/HEALTH FUND
If the student is a member of any private medical benefit fund, give details:
Fund Name Medibank Private

Benefit Tables hospital&extras

Membership No. 28851262H

If the student is covered by an ambulance subscription, give family subscription number.

RB:jh/23 July 2012

Outdoor Education Student Consent & Health Information Forms

NO

[ x ]

Indemnity/Information Regarding Risk in this Course:

Name:__Emmie Delchau______________________________ Date of Birth____05/02/1986_____________

For the following activity: HLPE 3532 INTRO to OUTDOOR EDUCATION on dates: JULY 2015 until DECEMBER 2015
I[name] __Emmie Delchau___________________________understand that although all possible care is taken, Flinders University cannot
accept responsibility for cancellations, loss or damage of equipment, accidents that may occur as a result of the field trip[s]. I accept
responsibility for my own actions and decision to take part in this activity. I have completed pre-exercise screening or have gained
clearance from my doctor to participate in physical activity or I acknowledge that I have chosen to forego pre-exercise screening against
the advice of the School of Education. I understand that the activities involved have an element of risk to person and property, and
although every effort is taken to minimise this risk I accept that there is a possibility of harm occurring.

Signed: _Emmie Delchau____________________________________date:_____24/07/15________________

Participant Safety on Field Trips

To be completed by the supervisor/leader and all other participants
As a participant on a field trip you are asked to READ, UNDERSTAND, SIGN and RETURN the bottom part of this form (in accordance
with requirements of the OHS &W Act, 1986). Whilst participating in the field trip you must carry your personal ID, hat, sunscreen,
medications, insect repellent and take food and drink provisions as required.
The following guidelines are for your personal safety. Failure to comply with reasonable instructions may result in you not being permitted
to participate in the remainder of the field trip.
1. Obey all reasonable directions from field trip leader. All boating operations require that you heed instruction and direction of the
boat operator, and all diving instructions from the dive leader.
2. Wear appropriate clothing for prevailing weather conditions (sturdy, enclosed footwear is required).
3. Stay clear of hazardous areas or dangerous locations (eg cliff edges, mine shafts, quarry faces and open slopes).
4. Behave in an orderly manner at all times.
5. Respect the property of others at all times such as that of landowners and places where you are accommodated.
6. Do not leave your group without notifying the field trip leader of your intended movements in time and place.
7. The consumption of alcohol or other drugs is forbidden in all formal University activities.
8. Firearms, spring or gas powered spears, unauthorised explosives and other weapons are not permitted on any field trip.
9. All participants are expected to assist in housekeeping duties as directed by the field trip supervisor.
10. University insurance , see http://ehlt.flinders.edu.au/archaeology/department/facilities/Field-Trips/EHLTFieldTrip_FlindersGuidelines.doc
-------------------Tear along here and return the completed form to the Field Trip leader --------------------I have read, understood and agree to the conditions of this field trip. I agree that I will not intentionally cause any concern regarding my
own health and safety or that of others on the field trip.
I hereby give permission for medical treatment to be administered to me in the event of an emergency.
Name: (BLOCK CAPITALS):

EMMIE DELCHAU
Mobile 0433905527

Date: 24/07/15

If you are under 18 years old, your care-giver also needs to sign the form, below.
Sign: Emmie Delchau

Date:24/07/15

Medical condition: Please advise if you suffer from any known medical conditions, including allergies which may affect your health or
safety on any field exercise, and if you will be taking any medications during any activities, as follows:
Medication: N/A
In the event of any emergency please contact the following person: (Next of kin)
Name: AARON DELCHAU

Contact No: 0400818855

This is a confidential form.

For the duration of the field trip/s this document will be held by the nominated contact person in the University.
Valid from: JULY 2015

To: DECEMBER 2015