Application for Activity Exemption and Declaration

MOTORBIKE

Children who will need assessment to engage in this high-risk activity(Required)

Name

Age

Describe in detail current skill level, developmental readiness and experience

Why is this activity part of the learning environment?(Required)

What specific learning outcomes or skills will be developed?(Required)

Why can these learning outcomes not reasonably be achieved through a lower-risk activity?(Required)

Identified Risks

Select all risks that are relevant to the environment

Loss of control

Collision with object, animal or structure

Falls from vehicle

Environmental hazards (holes, wells, puddles, unstable ground, debris)

Entrapment or crush injuries

Animal unpredictability

Other children entering zone

List additional risks unique to this specific activity(Required)

It is essential that Educators and Families show a clear understanding of associated risks.

How serious is the potential harm?(Required)

It is essential that Educators and Families show a clear understanding of potential harm.

Describe the clearly defined activity area and type of safe boundary indicators installed(Required)

e.g. Flags, ribbons, painted posts etc.

What controls are currently in place?(Required)

Provide detailed description to evidence understanding of mitigation strategies e.g. activity preparation steps, what kind of protective equipment, any specific rules, location of first aid.

What additional controls do you think the service would want you to establish?(Required)

e.g. grading of surface, create a viewing area, ensure wifi is accessible in the activity zone.

Please upload photographs of vehicle, protective gear and chosen location for activity here

Accepted file types: jpg, png, pdf, docx, Max. file size: 256 MB.

QUAD BIKE 90cc or Under

Children who will need assessment to engage in this high-risk activity(Required)

Name

Age

Describe current skill level and experience

Why is this activity part of the learning environment?(Required)

What specific learning outcomes or skills will be developed?(Required)

Why can these learning outcomes not reasonably be achieved through a lower-risk activity?(Required)

Identified Risks

Select all risks that are relevant to the environment

Loss of control

Collision with object, animal or structure

Falls from vehicle

Environmental hazards (holes, wells, puddles, unstable ground, debris)

Entrapment or crush injuries

Animal unpredictability

Other children entering zone

List additional risks unique to this specific activity(Required)

It is essential that Educators and Families show a clear understanding of associated risks.

How serious is the potential harm?(Required)

It is essential that Educators and Families show a clear understanding of potential harm.

Describe the clearly defined activity area and type of safe boundary indicators installed(Required)

e.g. Flags, ribbons, painted posts etc.

What controls are currently in place?(Required)

Provide detailed description to evidence understanding of mitigation strategies e.g. activity preparation steps, what kind of protective equipment, any specific rules, location of first aid.

What additional controls do you think the service would want you to establish?(Required)

e.g. grading of surface, create a viewing area, ensure wifi is accessible in the activity zone.

Please upload photographs of vehicle, protective gear and chosen location for activity here

Accepted file types: jpg, png, pdf, docx, Max. file size: 256 MB.

FARM VEHICLE

Children who will need assessment to engage in this high-risk activity(Required)

Name

Age

Describe current skill level and experience

Why is this activity part of the learning environment?(Required)

What specific learning outcomes or skills will be developed?(Required)

Why can these learning outcomes not reasonably be achieved through a lower-risk activity?(Required)

Identified Risks

Select all risks that are relevant to the environment

Loss of control

Collision with object, animal or structure

Falls from vehicle

Environmental hazards (holes, wells, puddles, unstable ground, debris)

Entrapment or crush injuries

Animal unpredictability

Other children entering zone

List additional risks unique to this specific activity(Required)

It is essential that Educators and Families show a clear understanding of associated risks.

How serious is the potential harm?(Required)

It is essential that Educators and Families show a clear understanding of potential harm.

Describe the clearly defined activity area and type of safe boundary indicators installed(Required)

e.g. Flags, ribbons, painted posts etc.

What controls are currently in place?(Required)

Provide detailed description to evidence understanding of mitigation strategies e.g. activity preparation steps, what kind of protective equipment, any specific rules, location of first aid.

What additional controls do you think the service would want you to establish?(Required)

e.g. grading of surface, create a viewing area, ensure wifi is accessible in the activity zone.

Please upload photographs of vehicle, protective gear and chosen location for activity here

Accepted file types: jpg, png, pdf, docx, Max. file size: 256 MB.

BUGGY / GOLF BUGGY

Children who will need assessment to engage in this high-risk activity(Required)

Name

Age

Describe current skill level and experience

Why is this activity part of the learning environment?(Required)

What specific learning outcomes or skills will be developed?(Required)

Why can these learning outcomes not reasonably be achieved through a lower-risk activity?(Required)

Identified Risks

Select all risks that are relevant to the environment

Loss of control

Collision with object, animal or structure

Falls from vehicle

Environmental hazards (holes, wells, puddles, unstable ground, debris)

Entrapment or crush injuries

Animal unpredictability

Other children entering zone

List additional risks unique to this specific activity(Required)

It is essential that Educators and Families show a clear understanding of associated risks.

How serious is the potential harm?(Required)

It is essential that Educators and Families show a clear understanding of potential harm.

Describe the clearly defined activity area and type of safe boundary indicators installed(Required)

e.g. Flags, ribbons, painted posts etc.

What controls are currently in place?(Required)

Provide detailed description to evidence understanding of mitigation strategies e.g. activity preparation steps, what kind of protective equipment, any specific rules, location of first aid.

What additional controls do you think the service would want you to establish?(Required)

e.g. grading of surface, create a viewing area, ensure wifi is accessible in the activity zone.

Please upload photographs of vehicle, protective gear and chosen location for activity here

Accepted file types: jpg, png, pdf, docx, Max. file size: 256 MB.

Application for Activity Exemption and Declaration

Activity Exemption Application and Declaration

Conditions where service will consider conducting a HIGH RISK Activity Exemption Assessment - have not yet been met

You may continue to submit a request for the Service to consider conducting a HIGH RISK Activity Exemption Assessment

MOTORBIKE

QUAD BIKE 90cc or Under

FARM VEHICLE

BUGGY / GOLF BUGGY

ACTIVITY SPECIFIC NON NEGOTIABLES

PLANNING - The activity:

ENVIRONMENT - The activity:

BOUNDARIES - The activity:

VISABILITY - The activity:

SUPERVISION - The Educator:

PROTECTIVE EQUIPMENT - The equipment:

FUEL AND MECHANICAL - During sessions:

MOTORBIKES / QUAD BIKES

FARM VEHICLES – Car, Buggy, Gol Cart - If a child is driving:

FARM VEHICLES – Car, Buggy, Gol Cart - Where the Educator is driving:

STOP CONDITIONS - Activity MUST STOP immediately if:

By submitting this form you request that the Service complete an Activity Exemption Assessment, understanding that approval may or may not be granted and that unless permission is granted, that the activity is not permitted during sessions of In Home Care.

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