Program Consent Form – Calm Mind Hub

Participants Details:

Name

Date of Birth

Age

Mobile Number

Email Address

Address

Suburb

State

Postcode

Address

Emergency Contact Name

Relationship to Participant

Emergency Contact Phone

Parent/Guardian's Details:

Name

Work Number

Mobile Number

Relationship to Participant e.g Parent:

How did you hear about us?

Referring Person's Name

Participant's Medical History Details:

Please indicate (tick) if participant is suffering or has suffered from any of the following conditions:

Please provide details of any conditions indicated above, current medication and additional medical conditions not listed:

Disclosure/Consent

I declare I have read all information on this form and I have completed all sections truthfully. I
acknowledge that Standing Strong Licensed Program Providers rely on this information to be complete and accurately to ensure participants wellbeing
during program participation.

I authorise my local Standing Strong Licensed Program Providers and it’s agents, in the case of injury or illness to me and or my child/dependant, to
release this information to such medical professionals as necessary, and to obtain any medical attention that Standing Strong Licensed Program Providers
and it’s agents deem appropriate, including ambulance or other transport as appropriate at the time. I agree that I am responsible for all costs associated
with responding to and treating me or my child/dependants illness or injury.

I acknowledge that the activities conducted by Standing Strong Licensed Program Providers may involve a degree of risk. I understand participation in
these programs is entirely at my and my child/dependant’s discretion, and I acknowledge that my child/dependant and I may choose to decline or cease
participation at any time.

I unconditionally release Standing Strong, Standing Strong Licensed Program Provider, it’s agents and their attendants to the fullest extent permitted by
law from all and any liability for any loss, damage or injury whatsoever incurred or suffered by my child/dependant and I, arising out of or in conjunction
with my and my child/dependant’s participation in any activity conducted by Standing Strong Licensed Program Providers.

I understand photographs and video footage may be taken during classes and programs for purposes that Standing Strong and Standing Strong Licensed
Program Providers deems to be appropriate, including for advertising, publicity and presentations. I understand if I do not consent to images being taken
o f me and/or my child/dependant I can notify my Standing Strong Licensed Program Provider directly.

Name

Date

Parent/Guardian Sign

Clear