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Guardian/Parent Details

First Name *

Last Name *

Email *

Phone *

Relationship to Young Person *

1 Participant 2 Interests 3 Emergency 4 Medical 5 Medicine 6 Uni. Study 7 Signature

Select Event(s)

What Outdoor Explore Program are you registering for? (You may select more than one) *

Young Person Details

First Name *

Last Name *

Date of Birth *

Participant's email or phone number (optional)

Address *

These questions are worded as if we are asking the young person themselves. If possible, we encourage the young person to participate in completing this section. When choosing to answer the following, please consider how important it is to you that we are aware of your identity and embrace it in the program.

Gender *

What pronouns do you use?

What is your cultural identity? *

Have you participated in any Outdoor Explore programs or events before today? *

About The Young Person

These next questions are addressed to the young person too, where possible, we encourage the young person to participate in completing this section. Answering these questions will help us to determine if this adventure is the right type of service for you. What you share will help us to understand you, so we can give you the best possible experience and provide you with the right support to keep you and others, safe and comfortable. We respect that talking about yourself and some subjects might be difficult, so we have kept it to one page and tried to include yes/no questions where possible. We intend to follow up with you to discuss the program in more detail.

Interests & Strengths

What interests you in joining an outdoor explore program? What are your strengths? What worries do you have about coming on an adventure with us?

How easy is it to calm down if something upsets or angers you? 1 = very easy, 5 = somewhere in the middle, 10 = very difficult 5

Do you have strategies or techniques you use to calm yourself? Have you participated in any risky or harmful behaviours to yourself or others? Such as self-harm, suicide, substance misuse, violence towards others or animals. Do you currently, or have you ever had a community service order, supervision order or youth conduct order? Do you have a behaviour support plan? Have you had a traumatic experience that might affect you in the program? Are you using a safety plan or do you have strategies to assist with any triggers or potential concerns? Is there anything that might stop you from attending the program?
E.g. Have you experienced bullying or been assaulted, and therefore would not attend if a particular person was attending. Is there anything specific you would like us to know about you?

Emergency Contact

First Name * Last Name * Relationship to participant * Contact phone number * Contact email address *

Medical Record

How do you rate the participant's overall fitness?*

Does the participant participate in regular exercise or sport? *

Has the participant ever or do they currently experience any of the following: *

Please provide details *

Can the participant swim unassisted for more than 50 metres? *

Can the participant ride a bike unaided? *

Does the participant wear glasses or contact lenses? *

Does the participant have any allergies? * What is the reaction to the allergy?
Please provide more information: What is the reaction to the allergy? What is the treatment? Have you ever been hospitilised? *

Do you have an anaphylaxis plan? *

Do you have a management plan for asthma, epilepsy/seizures, diabetes and/or any other significant health condition? *

Is the participant taking any form of medication? *

Does this medication need to be taken during the program? *

If yes, you will be asked for details on the next page

Do you consent to MYST staff administering non-prescription medication (if required)? e.g. clarentyne, panadol, ibuprofen *

Describe the participant's dietary needs

Medical Administration Consent

I understand that:

Mountain Youth Services Team Inc are not authorised to administer any prescription medication that is not provided by the parent/guardian and is not accompanied by the appropriate instructions as presented on this form.
If your young person/ward is anaphylactic and requires an EpiPen, we require that two (2) valid EpiPens be sent along on the day. As per Mountain Youth Services Team Inc’s procedures, one EpiPen stays with your young person/ward at all times and the other is held by the facilitator.

I understand and agree that:

I will provide the correct amount of medication for my young person/ward for the duration of the activity.
I will ensure the medication is separated into individual dosage for each time it is required to be administered,
I will ensure the medication is appropriately packaged with the clear, original label, in a container, zip lock bag or blister pack, and comes with instructions.
I will ensure medication is provided for all relevant medical conditions pertaining to my young person/ward.
I will ensure that the medication provided is within it’s expiration date.
I will provide a copy of all relevant medical action plans, for example: Anaphylaxis & Epipens Action Plan and Asthma Action Plan.

Tell us about the medication

What is the medication? * What is the dose? * At what time does it need to be taken? * Is the young person familiar with taking this medication? *

*Familiar means the young person has been taking the medication consistently for four weeks or more, and/or has had adequate time to adjust to a medication change

Is the young person responsible for self-administration? * If the medication is missed during allocated time, please indicate what steps should be taken *

Charles Stuart University Study

Child Client Consent Form

Implementing Feedback-Informed Treatment in the Outdoor Therapies: A Pilot Study

Researcher: Will W. Dobud, PhD

I have read the information provided and any questions I have asked have been answered.
The purpose of the study has been explained and I agree to participate in the study.
I realise I may withdraw consent at any time, without reason. This will not impact the service I receive.
I understand that participation is voluntary. I understand that participation in the study will include completing two short measures each session.
I understand that the information collected will be kept confidential, will only be used for the purposes of this research, and no identifiable information will be shared with the chief researcher. I have been advised as to what data is being collected, what the purpose is, and what will be with the data upon completion of the research.

Do you consent to this participant taking part in this study? *

Outdoor Explore Program Registration