Medical Information & Indemnity Form

Greetings to all participants of CUDAS 12

Childs name: _____________________

Plans have now been finalised for the 2012 Queenstown Rugby Tour (CUDAS 12) which will take place from Saturday 30 June to Saturday 30 June. The tour should prove one of the highlights for your sons time at the Mosman Junior Rugby Club and a great opportunity for him to develop bonds with his peer group that may last a lifetime. As such, the week together overseas is an important occasion for the boys to share many experiences in addition to playing rugby against three teams from the Central Otago region of New Zealand. While there are games or training during 5 of the days away, the week also includes a broader social and activities program designed to make it a stimulating and enjoyable experience for all children. As you know, we welcome all families participation in that program. One of the main aims of the tour is to establish in participants a sense of teamwork and belonging. It is important that, where families join the tour, they recognise the primary goal is for the boys to undertake their activities as a team. There are opportunities for time-out as a family within the itinerary. An Activity Program for the week has been designed and has been included in separate materials to you. Boys will be travelling to New Zealand in a group, on the 30 June 2012. Accommodation for the week through until 7 July will be at Pinewood (http://www.pinewood.co.nz/). The boys will sleep and eat in one large unit that houses kitchen, dining, shower/bathroom facilities and sleeps 24 individuals in 4 bunkrooms. A parent is rostered on duty to sleep in the unit with the boys on each of the 7 nights. Many other parents/families are accommodated in units close by. Return travel is either on Saturday 7 July or at a later date after the child has been returned to the complete care of his parent(s). PLEASE NOTE that you will be responsible for ensuring that your child arrives at Sydney International Airport on Saturday 30 June 2 hours prior to the flight, that he has a valid international passport, and that, where appropriate, he is met on arrival back into Sydney International Airport and his transport home from the airport is arranged. All parents are asked to sign the attached Deed of Indemnity and to read the attached medical information and complete and return the Medical Form. If you will not be in Queenstown with the boys and your son takes medication for a condition, please ensure you hand the medication, with detailed instructions, to the Tour Manager or Tour Organiser by Friday 22 June 2012. Thank you for your ongoing support. Key Contacts Tour Manager David McCracken 0438 616 967 Tour Coach Tim Wallace 0431 581 008 Assistant Coach James Hodgkinson 0414 458 752 Treasurer Duncan McLennan 0401 148 293 Cuda Crew Manager Lisa Ryan 0425 254 213 Catering Julie Dutaillis 0403 750 411 Laundry David Harrison 0412 259 751 _______________________________________________________________________________

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Medical Information & Indemnity Form

Childs name: _____________________

DEED OF INDEMNITY
MUST BE SIGNED BY ALL PARENTS/GUARDIANS Queenstown Rugby Tour, New Zealand 2012 (CUDAS 12). Mosman Junior Rugby Club, Under 12s. 30 June 7 July 2012. Please return this form to David McCracken no later than 22 June, 2012. PERMISSION: I agree to my child's attendance at and participation in the above-mentioned tour and to his taking part in any activities arranged in connection with the tour. I authorise my child's/ward's name and any photographs, sound and film recordings taken as part of this tour to be used for the promotion of the of the annual tour to the club, media and to the general public. I also authorise designated individuals to supervise my child while taking medication as requested by me on this form. In the event of any accident or illness, I authorise the obtaining of such medical assistance on my behalf that my child may require. I also undertake to pay medical fees and/or costs of drugs which may be incurred while my child is on the tour. Child's Name: ________________________________________________ Emergency Contacts: 1. In New Zealand during tour dates Name: __________________________ Relationship: _____________________ Accommodation: __________________ Mobile No.: _______________________ Other contact info: _________________ ________________________________ 2. In Australia during tour dates Name: __________________________ Relationship: _____________________ Accommodation: __________________ Mobile No.: _______________________ Other contact info: _________________ ________________________________ Name: __________________________ Relationship: _____________________ Accommodation: __________________ Mobile No.: _______________________ Other contact info: _________________ ________________________________ Name: __________________________ Relationship: _____________________ Accommodation: __________________ Mobile No.: _______________________ Other contact info: _________________ ________________________________

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Medical Information & Indemnity Form

Childs name: _____________________

Special needs of my child of which you should be aware (eg. allergies, medication - please provide full details on the Medical Information form): ______________________________________ _______________________________________________________________________________ I/We understand that although participants, tour organisers and participating parents will attempt to minimise any risk of personal injury within practical boundaries, accidents do happen and all physical activities carry the risk of personal injury. I acknowledge that there is an inherent risk of personal injury in physical activities that will be undertaken as part of this tour. Further, I/We understand that while everything is done to ensure both the comfort and safety of those attending CUDAS 12, and whilst every care will be exercised by those who are in charge, the Mosman Junior Rugby Club, Tour Officials, and Club representatives are not responsible in any way for any accident or sickness which may occur or happen through any circumstances. Signature of Parent or Guardian: Print Name of Parent or Guardian: Date: ________________________________________ ________________________________________ _________________________________________

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Medical Information & Indemnity Form

Medical Information

Childs name: _____________________

You are asked to disclose all information relating to any medical condition and treatment your child is currently undergoing. Medication brought on tour must be in ORIGINAL PACKAGING with your CHILD'S NAME, DOSAGE, and DOSAGE TIMES clearly marked. A tour official or parent will supervise the self-administration of all medication. Please provide details of any procedures recommended by your medical practitioner in the event of a crisis (e.g., asthma attack, epileptic seizure). Attach a separate sheet or management plan if necessary. Privacy Statement CUDAS 12 is collecting and storing the information you voluntarily provide to enable support where appropriate. The information will be provided to tour organisers and parent helpers where necessary and you consent to this disclosure. The information will only be used for the purpose for which it was collected. Medical Details 1. Please provide full details of any medical or health condition (eg allergies, asthma etc) experienced by your child. _______________________________________________________________ _______________________________________________________________ Is your child presently taking medication? If yes, please read and complete the following: Name of Dosage Times to Before/with/after Medication be Taken meals (or n/a) Y/N Reason/ Condition

2.

_______________________________________________________________ _______________________________________________________________ 3. Please give details of procedures recommended by your medical practitioner in crisis situations (eg asthma attack, epileptic seizure) _______________________________________________________________ _______________________________________________________________ 4. Does your child have an allergic reaction to any type of medication or food? If yes, please give full details attaching a separate sheet of paper if necessary _______________________________________________________________ _______________________________________________________________ 5. Please provide details of any other condition that we need to be aware of such as bedwetting, sleepwalking, nightmares, ADD/ADHD, etc. _______________________________________________________________ _______________________________________________________________ 6. Has your child been fully immunised? Y/N Y/N

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Medical Information & Indemnity Form

Childs name: _____________________

It is your responsibility to provide all medication as originally packaged, comprehensive instructions and equipment for its administration and adequate supply for the duration of the tour. 7. Doctors Name: Address: Contact Number: 8. Medicare No.: Health Fund No.: ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ Y/N Medicare & Private Health Insurance Private Health Fund: ___________________________________________ Does this Health Fund cover ambulance fees?

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Medical Information & Indemnity Form

Insurance Introduction The following information is available on the ARU website.

Childs name: _____________________

1. The current ARU Sports Injury and Liability policy extends to cover insured players and officials whilst overseas on representative and/or club matches. Liability cover is excluded in USA and Canada. The details of the insurance is attached to this document. 2. Although the policy covers overseas it is recommended by the ARU that Travel Insurance be effected for all players and officials to complement the cover provided. Travel Insurance policies generally provide high limits of medical expense coverage (the ARU policy limits medical expenses to $2,000 per injury and does not include coverage for illness) as well as other covers such as baggage, money, loss of deposits, emergency assistance etc.. If effecting travel insurance it is important the policy does not exclude injuries arising from playing rugby. Refer to ARU website http://www.rugby.com.au/tryrugby/Administration/Insurance/InsuranceOverseas RugbyTours.aspx 3. If required Gow-Gates Insurance Brokers (see below) can arrange travel insurance for members of the touring party with the ARU Sports Insurer, QBE Insurance, which complements the existing Sports Injury coverage and does not exclude injuries resulting from rugby. The cost of this insurance has been indicated by Gow-Gates to be approximately $80 per person with coverage as summarised below. (to be confirmed by Gow-Gates) PERSONAL ACCIDENT A. Players and Officials (i)Capital Benefits - Not Insured (i)Temporary Total Disablement - Not Insured *Note coverage provided for this under ARU Sports policy for Players and Officials B. Other party Members (i) Capital Benefits - $100,000 (i)Temporary Total Disablement - $500 per week OVERSEAS MEDICAL OMEGA AND ADDITIONAL EXPENSES Sum Insured: $ 500,000 KIDNAP AND RANSOM Sum Insured: $ 250,000 BAGGAGE, TRAVELLERS' CHEQUES, TRAVEL DOCUMENTS, CREDIT CARDS Sum Insured: $ 10,000 *Note - Money limited to 25% of the above or 1,000 whichever is the greater. LOSS OF DEPOSITS AND CANCELLATION CHARGES Sum Insured: $ 10,000 Page 6 of 7

Medical Information & Indemnity Form

Childs name: _____________________

*Note: Amount above are per person. Policy has an aggregate limit of $2,000,000 any one occurrence. If you require Gow-Gates to provide a firm quotation for travel insurance for you, please contact: Gow-Gates Insurance Brokers Pty Limited (ABN 12 000 837 785) GPO Box 4731 SYDNEY NSW 2001 Ph.: Direct 02 8267 9908; Office 02 8267 9999 Fax.: 02 8267 9998 web page: http://www.gowgates.com.au/ 4. Alternatively, if required similar insurance can be arranged through ITS Travel (tour organisers) and their insurer. Details are are available from Mark Waters (ITS Travel) direct and are available in individual and family packages. Mark has supplied two different quotes for Insurance Family & Single. This includes a 20% discount off normal rates. If any of the families require Suresave Insurance then they need to complete the following Application Form and return to Mark. You must also be aware of the Product Disclosure Statement and the Financial Services Guide and must consider their own personal situation before deciding on what policy then require http://www.suresave.net.au/components/SS09BrochurePDSV1.pdf http://www.suresave.net.au/components/SSCerberus_Appform_1009.pdf The website is http://www.suresave.net.au/index.php?a=1&showerr=1 I ... (Parent or guardian of player touring New Zealand from 30 June 7 July 2012 to play rugby) have read and fully understand that additional insurance cover is available to my son (Players full name) and my family accompanying him on the CUDA12 rugby tour. Signed Date ././.

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ARU Sports Injury and Liability Programme Overview

This programme has been arranged by the Australian Rugby Union on behalf of all insured persons. As a measure of your Unions support to players, clubs and officials, the ARU has arranged insurance cover as set out in this document for your benefit and risk protection.

INSURANCE BENEFITS
Personal Accident Public & Product Liability Professional Indemnity Management Liability
Who? All Players, coaches, trainers, managers, administrators, voluntary workers, selectors, referees, touch judges, ball boys, medical officers, physiotherapists and ambulance officers; and all directors, officers, employees, executive officers, office bearers, members and committees of the insured. What? Basic cover for participants who suffer injuries arising out of participation in Rugby
When?

What? Cover for your legal liability in respect of bodily injury and property damage When? Arising out of your sporting activities which means playing or administering the sport including social and fundraising activities of the club/union

What? Cover for your legal liability for breach of professional duty through an act, error or omission When? Arising out of an act, error or omission committed for or on behalf of the Club/Union

What? Cover for Clubs and their officers for claims against them for alleged Wrongful Acts When? Arising out of an alleged wrongful act whilst acting for or on behalf of the Club/Union.

Playing in official club or representative matches As well as: Organised Training, Travelling between home/work and training or games, Staying away from home for a tour and Administrative and social activities of the club/union Benefits? Capital Benefits A lump sum benefit for permanent injuries Non-Medicare Medical Expenses Reimbursement of incurred medical expenses where there is no contribution from Medicare Weekly Benefits Loss of Income cover for the period that you are unable to work due to your rugby injury As well as various additional benefits refer to the full policy for details.

Benefits? Public Liability $20,000,000 any one occurrence Product Liability $20,000,000 any one occurrence and in the aggregate Excess $1,000 each and every occurrence

Benefits? Professional Indemnity $10,000,000 any one occurrence and in the aggregate Excess $1,000 each and every claim

Benefits? Directors and Officers Liability Club Reimbursement Breach of Professional Duty including: Breach of Trade Practices Legislation, Breach of Contract, Libel and Slander, Intellectual Property Limit of Liability $1,000,000 any one claim and in the aggregate Excess $1,000 each and every occurrence

Details continued overleaf

For further ARU Insurance information visit: www.gowgatessport.com.au/rugby

Gow-Gates Insurance Brokers Pty Ltd (A.B.N. 12 000 837 785)

Play with Confidence

INSURANCE BENEFITS
Capital Benefits
Capital Benefits are a lump sum benefit that is provided in the event of Death and Permanent Disability. Benefits are payable based on a table of events available in the full policy wording. Some of the benefits payable include: Death $100,000 Paraplegia and Quadriplegia $400,000 Loss of sight of one eye $150,000 Loss of use of one limb $150,000

Non-Medicare Medical Benefits

Non-Medicare Medical Benefits covers medical expenses for which there is no reimbursement (wholly or partly) from Medicare Benefits Covered - 80% of Non-Medicare Medical Benefits - Maximum Payable $3,000 - $100 excess The Health Insurance Act (Cth) 1973 does not permit the insurer to contribute to expenses which are wholly or partly claimable through Medicare Examples of expenses covered: Private Hospital Accommodation Physiotherapy Examples of expenses not covered: Doctors and Surgeons Fees X-Rays

Weekly Benefits
Weekly benefits are payable whilst you are wholly and continuously unable to work and/or attend school or studies. Income Earners 80% of gross weekly income (net of business expenses) up to $300 per week for 52 weeks. A 28 day excess applies Non-Income Earners 80% of authorised domestic help up to $300 per week for 52 weeks A 14 day excess applies Full Time Students 80% of authorised home tutor costs up to $300 per week for 52 weeks A 14 day excess applies

Other Benefits
There are other benefits payable under the ARU Insurance Programme for expenses which may be incurred as a result of a rugby injury. Some of these benefits include: Funeral Expenses Parents Inconvenience Travel and Accommodation Overseas Medical Expenses Full details of these benefits are contained in the policy wording. Please contact Gow-Gates for further information.

For further ARU Insurance information visit: www.gowgatessport.com.au/rugby

or contact Gow-Gates directly Phone: 1800 811 371 | Email: rugbyins@gowgates.com.au GPO Box 4731 Sydney NSW 2001 | Level 8, 491 Kent Street Sydney NSW 2000

When you register to play with a Rugby Union Club, you are reminded that Rugby Union is a body contact sport. Potential, notwithstanding all safety guards, exists for a player to sustain injury. Players must therefore prepare themselves for the game by having a commitment to training and a high level of fitness. As a measure of your club and your unions support to players and officials, the ARU has arranged insurance cover as set out in this document and for your benefit and risk protection. In addition to these policies all players and officials are encouraged to take out private health insurance, life insurance and top up cover over and above that is outlined above to ensure individual needs and circumstances are met. For any advice or additional insurance cover that you may require please contact Gow-Gates. This summary is prepared by Gow-Gates Insurance Brokers Pty Limited ABN 12 000 837 785 AFSL 245423