Consent Form
Introduction
Any person can directly register on the Safe
Return Home system if they are able to function independently and
provide informed consent. If informed consent is not
possible, a representative of the registrant is required to
complete part 2 of this form.
Safe Return Home Consent Form
Part 1: Consent Form - must be completed
I.........................................................on
behalf
of the registrant/the registrant
(Registrant’s name here..........................................), hereby authorise Applied Aged Care
Solutions Pty Ltd to collect, store and use the Registrant’s
personal, sensitive and health information in a database and to
disclose such information to the following bodies
as part of providing its Safe Return Home program:
| New South Wales, Victoria, Queensland, Tasmania,
Australian Capital Territory, South Australia, Western
Australia, and Northern Territory Police Department
Officers |
I further authorise Applied Aged Care
Solutions Pty Ltd to disclose the following information about the
Registrant to the general public on its website as part of providing
its Safe Return Home program if the Registrant has been reported as
missing to the Police, Emergency Services or a Community
Agency:
Name;
Photograph;
Age;
Sex;
Suburb;
How
long missing
Telephone number of local Police
service;
Yes No (please tick)
Part 2:
Complete if the registrant is unable to give informed consent:
I warrant that I am the
Registrant’s representative for the purposes of providing this
consent, being the Registrant’s (please tick one of the following):
1.
Parent
of the Registrant, if the Registrant is a child; or
2.
Next of kin
or other family member acting on behalf of the registrant; or
3. Person otherwise empowered in accordance
with the law to perform any functions or duties or exercise powers
as an agent of or in the best interests of the Registrant
(If you have selected this option, please tick one of the
following below ).
New South
Wales
Guardian appointed in
accordance with the Guardianship Act 1987 (NSW);
Alternative
guardian appointed in accordance with the Guardianship Act 1987
(NSW);
Enduring guardian appointed in accordance with the
Guardianship Act 1987 (NSW); or
Person named as a guardian in a guardianship order.
Victoria
Attorney appointed under an
enduring power of attorney (medical treatment) in accordance with
the Medical Treatment Act 1988 (Vic); or
Guardian appointed
in accordance with the Guardianship and Administration Act 1986 (Vic).
Queensland
Attorney for personal
matters appointed by the adult under an enduring power of attorney
in accordance with the Powers of Attorney Act 1998
(Qld);
Guardian appointed in accordance with the Guardianship and
Administration Act 2000 (Qld);
The guardianship and
administration tribunal; or
The
court.
Tasmania
Guardian or Person responsible
appointed in accordance with the Guardianship and Administration Act 1995 (TAS).
Australian Capital
Territory
Guardian
appointed in accordance with the Guardianship and Management of
Property Act 1991 (ACT).
South Australia
Enduring Guardian
appointed in accordance with the Guardianship and Administration Act
1993 (SA); or
Guardian appointed in accordance with the
Guardianship and Administration Act 1993 (SA).
Western Australia
Attorney appointed
under an enduring power of attorney (medical treatment) in
accordance with the Guardianship and Administration Act 1990
(WA); or
Guardian or Person responsible appointed in
accordance with the Guardianship and Administration Act 1990 (WA).
Northern Territory
Attorney appointed
under an enduring power of attorney in accordance with the Powers of
Attorney Act (NT); or
Guardian appointed in accordance with
the Adult Guardianship Act (NT).
I also warrant that my consent to the
registration of the Registrant in AACS’s Safe Return Home program
accords with any expressed wishes of the Registrant prior to their
loss of capacity to consent on behalf of themself.
Name (please
print):................................................................................
Signature:.................................................................................................
Address:...................................................................................................
City:.................................... State:.....................
Postcode:
Date:......../........./..........