3rd May 2014
CLUB TOUR TO CANBERRA
Willoughby Swim Club will be travelling to Canberra to compete in the Ginninderra Swim
Club meet on 21 and 22 June 2014. This is a SHORT COURSE meet and will be a
qualifying meet for all winter competitions. Children aged 12 years or under should be
accompanied by an adult/s.
Total Cost is: $150 for first swimmer, $100 for sibling swimmer, $120.00 for adults.
This payment includes pool entry, breakfasts, lunches, athlete dinners, accommodation and
coach transfers. Adults purchase restaurant meal on Saturday night. If adults are travelling
separately please let tell us when entering your swimmer.
Please be at Chatswood Public School by 5.45 am on Saturday 21 June 2013. As the bus
will be departing at 6.00 am (at the latest). Our scheduled return to Chatswood Public School
will be approx. 7.00 pm on Sunday. Chatswood Public School – Corner Pacific Highway and
Centennial Ave, Chatswood. The coach will depart from Centennial Ave.
We will be staying at the Styles Eaglehawk Canberra, 999 Federal Highway North, Canberra
ACT, 2620
Tel: +61 2 6241 6033
Fax: +61 2 6241 3691
Coach contact is:
Tour Manager is:
Paul Hardman
Tbc
Can you please complete the attached permission slip and place in Club box, along with the
booking form. Enquiries about entries should be directed to Jodie Spano
(wsc.entries@gmail.com) by Monday 2nd June 2014. Please be aware of the QT and please
advise your swimmers times along with entries. No late entries will be accepted after this
date. Please note the Age Group Code of Conduct applies.
Thank you and should you require any further information, please contact Paul or myself.
Regards
Jodie Spano
Race Secretary / Vice President
ABN 44 683 994 182
PERMISSION FORM
A parent or guardian is requested to sign this permission form enabling their Son/Daughter
___________________________________________________________________________
to travel to and from Canberra by coach to participate at the Ginnenderra Swim Carnival
which will be held at the AIS/ accommodation at Styles Eagle Hawk, on Saturday 21 and
Sunday 22 June 2014. Please include on the form: (any birthdays, special times, while we are
away)
Special Request:
___________________________________________________________
Please also complete the separate booking form and forward along with this permission slip
and the medical release form with full payment (including races entry fees).
Payment can be made either via cheque or EFT into the WSC account.
I give permission for my son/daughter to travel by coach, with the Willoughby Swim Club to
Canberra and return.
……………………………..
Parent/Guardian/signature
………………………..
Home Phone Number
……………………………..
Print Name
ABN 44 683 994 182
……………………
Mobile Number
Medical Release Form
Name of
Swimmer:_______________________________________Date:________________
Parental Consent
This medical release form must be signed by a parent or legal guardian for EACH
swimmer of the Willoughby Swim Club Inc on tour. If the swimmer is 18 years of age or
older, the swimmer must also sign this form.
MEDICAL RELEASE
I CERTIFY THAT, TO THE BEST OF MY KNOWLEDGE AND BELIEF,
___________________________ (NAME OF THE SWIMMER) IS IN GOOD PHYSICAL
CONDITION AND HAS NO CONDITION WHICH WOULD IMPAIR PARTICIPATION IN THE
PROGRAM. IN CASE OF INJURY, I HEREBY GIVE THE WILLOUGHBY SWIM CLUB INC
PERMISSION TO ACT ON MY BEHALF IN SEEKING MEDICAL TREATMENT FROM ANY
PHYSICIAN, HOSPITAL OR CLINIC FOR MY CHILD IN THE EVENT THAT SUCH TREATMENT
IS DEEMED NECESSARY. I GIVE PERMISSION TO THOSE ADMINISTERING MEDICAL
TREATMENT TO DO SO USING METHODS DEEMED NECESSARY. I ABSOLVE
WILLOUGHBY SWIM CLUB INC FROM ALL LIABILITY WHILE ACTING ON MY BEHALF IN
THIS REGARD
___________________________
Participant Signature (if over the age of 18)
____________________________
Parent/Guardian Signature:
___________________________
Home Phone:
____________________________
Parents Daytime Phone:
If parents are not available, please call the person designated below:
Name: _________________________________
Address: _______________________________
City/State/Postcode: __________________________ Phone: _________________
Relationship: ____________________________
Additional comments regarding medical history, allergies, penicillin or drug reactions,
etc…...which may be needed in rendering medical treatment:
___________________________________________________________________
Medicare no of swimmer: _________________________________
Parent/Guardian Insurance Information:
Company Name:
Policy #:
_________________________________
Address
_________________________________
ABN 44 683 994 182
_____________________
Phone:
_____________________