KOE Waiver & Medical Form

KOE Risk Warning, Waiver and Medical Form

Katherine Outback Experience & Outback Productions
Form to be completed by Parent / Legal Guardian if the Participant is under the age of 18 years.
Name of Participant:*

First NameLast Name
Age of Participant*
Name of Parent/ Legal Guardian if Participant is under the age of 18 years:

First NameLast Name
Email*
Mobile Number*
Risk Warning and Acknowledgement

Your participation in the recreational activities supplied by Katherine Outback Experience and/ or Outback Productions (SUPPLIER) may involve risk. Risks may include (but are not limited too) injury or death caused by falling off a horse, or being kicked, struck, bitten, bumped or stepped on by a horse, dog, goat, cattle or other animal/s.

The risks involved may result in personal injury including death. Prior to undertaking any such recreational activity, you should ensure you are aware of all of the risks involved, including those risks associated with any health condition you may have.

By signing below, you acknowledge, agree, and understand that participation in the recreational services provided by the SUPPLIER may involve risk. You agree and undertake any such risk voluntarily and at your own risk.

Exclusion, restriction or modification of rights under the Australian Consumer Law (NT)

Under the Australian Consumer Law (NT), statutory guarantees apply to the supply of certain goods and services, including recreational activities.

It is possible for a supplier to ask you to agree that these statutory guarantees do not apply to you. If you sign this form, you will be agreeing that your rights to sue the supplier because services provided were not in accordance with the guarantees are excluded, restricted or modified as set out below.

By signing below, you agree that the liability of SUPPLIER for any death or personal injury (as defined in section 48 of the Consumer Affairs and Fair Trading Act (NT) that may be suffered by me (or a person from whom or on whose behalf I am acquiring the services) resulting from the supply of recreational services is excluded.
Terms & Conditions
I am applying for the participant to participate in activities conducted by Katherine Outback Experience and/ or Outback Productions and agree to the following terms and conditions (please tick):*

The participant will only ride the horse in a safe and controlled mannerThe participant will wear an Australian Standard Approved helmet and the correct footwear at all timesThe participant will read and follow all signs on the property and follow all instructionsThe Instructor/Guide may cancel participation in any of the activities if the participant does not comply with any of these terms and conditions.
Medical Form
Parent / Emergency Contact

In the case of any emergency the following information is intended to assist.
Name*

First NameLast Name
Relationship to Participant*
Contact Number/s*
Email*
Personal Information
Are there any learning difficulties and/ or mobility issues that need to be discussed so the Instructors/ Guides are able to accommodate accordingly?*

YesNo
If Yes, please describe:
Please tick: Any pre-existing medical or other condition that may affect or risk other persons or myself.*

NilAsthmaDiabetesEpilepsy / FitsFaintingBlackoutsDisabilityBack injuryHeart ConditionBlood ConditionPregnancyDizzinessMigrainesUneven PupilsMedicationsAllergic ReactionsRecent injuryOther
If other, please describe
Please detail any allergies (including food) and reactions:
Medication
Is it necessary for you or your child to carry any form of medication at all times?*

YesNo
Name of drug:
Frequency:
Dosage:
Consent to Medical Attention

By signing below, I authorise the instructor in charge to administer first aid and call an ambulance. I agree to bear any cost thereby incurred.
Signature of Parent / Legal Guardian.*
Name*

First NameLast Name
Date*

MonthDayYear
Date
Privacy Statement – Privacy Act 1998
By completing this form you are supplying the Provider with personal information about yourself. This information is needed to ensure your safety during your time with us. The Provider is required to collect this information by our insurance company and by the department of Workplace Health and Safety. This information you provide will not be supplied to any other organisation or used for any other purpose than that which is stated above
Should be Empty:

KOE Risk Warning, Waiver and Medical Form

Terms & Conditions

Medical Form

Parent / Emergency Contact

Personal Information

Medication

Consent to Medical Attention

Privacy Statement – Privacy Act 1998