Bay Connection Bus Trips Application Form

BAY CONNECTION BUS TRIPS

APPLICATION FORM

Applicant Details

Full Name *

Date of Birth *

Gender *

MaleFemale

Country of Birth *

Address *

Street address *

City *

Postcode *

Contact Number *

Do you have any dietary requirements? *

YesNo

Please specify *

Language spoken at home *

Are you able to understand/speak English? *

YesNo

Does your carer attend outings? *

YesNo

Carer's Full Name *

Carer's Contact Number *

Carer's Address *

Are you involved in any other 'outings'? *

YesNo

With which organisation, and how often? *

Emergency Contacts

Please provide the names and conact details of two people that we could contact in an emergency situation. These people would not be contacted in any other situation without your consent.

First Contact

Full Name

Contact Number *

Secondary Contact Number

Relationship to Applicant *

Second Contact

Full Name *

Contact Number *

Secondary Contact Number

Relationship to Applicant *

Medical and Health Details

In the case of an emergency, these details would be passed on to Ambulance/Hospital personnel.

Your Doctor's Surgery/Medical Centre *

Doctor's Name *

Doctor's Contact Number *

Name of Chemist *

Chemist's Contact Number *

Please list current medications

Do you have any health problems that we should know about?

Mobility

I am able to walk unaided *

YesNo

I am able to get on/off the bus unaided *

YesNo

I can use the stairs *

YesNo

I can only walk limited distances *

YesNo

I use a walking stick *

YesNo

I use a walking frame *

YesNo

I use a wheelchair *

YesNo

Vision

I wear glasses *

YesNo

I use a cane as a visual aid *

YesNo

I am legally vision impaired/blind *

YesNo

Hearing

I wear a hearing aid *

YesNo

I have some difficulties hearing *

YesNo

Do you have any special mobility, vision or hearing requirements that we should be made aware of?

Is there any further information you wish to provide?

Declaration

I participate in these activities at my own risk. *

I hereby indemnify and release City of Canada Bay Council, it's employees and volunteers from all liability for injury, loss or damage connected with my participation in these activities. *

I consent to receiving any medical treatment that Council staff consider desirable during or directly after the activity, an dI affirm that all medical information relevant to my participation in these activities has been supplied. *

Applicant Signature *

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Date