Youth for the Mountain Pygmy-possum event consent form

Parent/guardian consent

Name of parent/ guardian *

Name of child attending *

By confirming this purchase I give my give consent for my child to attend Youth for the Mountain Pygmy-possum Event at Melbourne Zoo on the 2 October 2019. *

Yes

I understand that students are supervised by Learning Experiences staff from 10am – 3pm with the exception of the morning tea and lunch breaks. *

Yes

I have discussed with my son/daughter that he/she is to remain in the Zoo grounds and to be punctual when returning from breaks. *

Yes

I authorise Learning Experiences staff to consent where it is impractical to communicate with the Emergency Contacts listed below, to my son/daughter receiving first aid, medical or surgical treatments as may be deemed necessary. *

Yes

I agree to terms and conditions of Zoos Victoria *

Yes

Emergency contacts

Emergency Contact 1 - Parent/guardian name *

Phone number *

Emergency contact 2 *

Phone number contact 2 *

Optional information

Does your child have any special needs that could affect their participation in the program?

Yes
No

Media consent

By completing this check box, I give consent for Zoos Victoria, or a third party authorised by Zoos Victoria, to capture images, sound recordings and/or footage (together, Media) of the child named in this form, and to use that Media in the manner described below. The Media may be used in Zoos Victoria’s advertising and promotional material, and may be distributed via a range of media, including (but not limited to) print, television and radio promotions, Zoos Victoria websites, and/or social media channels, such as Facebook, Instagram, Twitter, Pinterest or YouTube. The Media may be digitally edited, altered, distorted, used in whole or in part, in conjunction with other images, graphics, text and sound in any way whatsoever and without restrictions. I agree that I have voluntarily provided this consent and acknowledge that Zoos Victoria’s use of the Media does not give you any right to require payment or acknowledgement. There is no time limit on the validity of this consent. *

Yes, I give consent for my child to be photographed/filmed during Youth for the Mountain Pygmy-possum
No, I do not give consent for my child to be photographed/filmed during Youth for the Mountain Pygmy-possum

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