Read Microsoft Word - Childrens Holiday Camp application form.docx text version

ABN 67 004 456 222 3704 Point Nepean Rd, Portsea 3944 P: (03) 5984 2333 F: (03) 5984 1676 E: [email protected] W:

Children's Holiday Camp Application Form

Please write clearly, answering all questions (circling answers as required) and return form to your local organizer (country groups) or to the camp directly (individual bookings). Please keep a copy of the form and make sure to advise of any changes. Child's details Surname __________________________________________ Given name ______________________________ Male ( ) Female ( ) Address ________________________________________________________________________________________________ ___________________________________________________________________________ Postcode __________ Medicare number _______________________ Expiry date ___ / ___ / ___ Child's number on card _____ Private health insurer _____________________________________ Number _____________________________ Ambulance subscriber Yes/No Number ____________________________Last tetanus injection _______ Child' Doctor's name ______________________________________ Phone ____________________________ Child's first language? ______________________________ Parent / guardian details Surname _________________________________________ Given name ______________________________ Phone (h) _______________________________________ Phone (w) __________________________________ Mobile _________________________ Email ________________________________________________________ Surname _________________________________________ Given name ______________________________ Phone (h) _______________________________________ Phone (w) __________________________________ Mobile _________________________ Email ________________________________________________________ Are there any accommodation, intervention or custody orders concerning the child? Yes / No If yes, please provide details ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ DOB ___ / ___ / ___ T-shirt size 8 10 12 14 16 18


Child's medical and personal details: Asthma: Does your child have asthma? Yes/No Does your child have an asthma management plan? Yes/No ­ (if you answered yes, please send a copy of the plan or complete and attach the separate asthma management plan form). Does your child carry an asthma reliever (eg ventolin)? Yes / No Is your child able to manage use of their asthma reliever without help? Yes / No Complex behaviours: Has your child been diagnosed as having complex behaviours? Yes / No If you answered yes, please help us understand the nature of the behaviour. ADHD ­ inattentiveness Yes / No ADHD ­ hyperactive and impulsive? Yes / No ADHD ­ both? Yes / No Oppositional Defiance & Conduct Disorder? Yes / No Mood disorders (anxiety)? Yes / No Autism spectrum disorder? Yes / No Type of ASD _________________________________________ Allergies: Does your child experience acute allergic reactions? Yes / No What brings about the acute reaction? ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Does your child carry an epinephrine injector (eg Epipen) for this allergy? Yes / No Does your child have non-acute, general allergies? Yes / No What is your child allergic to? ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ What is your preferred treatment? ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Medication: Will you require camp medical staff to give medication to your child during camp? Yes / No If yes, please clearly put a tick in the time boxes alongside the medication name and dose. Medication & dose

8am 10.30am 12.30pm 2.30pm 5pm 9pm As required

Do you agree to medical staff administering paracetamol if required? Yes / No CONFIDENTIAL

Bedwetting: Does your child wet or soil their bed? often / occasionally / never Travelsickness: Does your child experience travel sickness? often / occasionally / never

Dietary requirements: Halal / Kosher / Vegetarian / Other (please describe) ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ General abilities and interests: Is your child confident in the water? Yes / No Easily able to swim 25m? Yes / No

What are your child's general interests (eg. reading, art, performance, sports)? ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ What is the best way for us to help your child deal with upsets at camp? ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Does your child have an intellectual disability? no / mild / moderate / severe / profound. If so, how will this affect their time at camp and how should we be of assistance? ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Does your child have a physical disability? Yes / No If so, how will this affect their time at camp and how should we be of assistance? ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Social situation: Does your child make friends easily? Yes / No ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Has your child stayed away from home before? Yes / No ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ If your child is homesick would you prefer us to: Contact you immediately? Yes / No Have them talk to you immediately? Yes / No Support them through the first 2 days of camp (even if this means a few tears!)? Yes / No If your child's homesickness is affecting their enjoyment of camp are you prepared to pick them up? Yes / No


Have there been any significant emotional stresses in your child's life that may affect their camp experience? If so, please describe: ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Does your child have any cultural beliefs or practices we should be aware of? Yes / No ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Additional information: Please provide any additional information you feel may be useful for us to know to enable your child to get the most out of their stay at the camp. ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Consent to participate in activities and receive any urgent medical attention:

I, the undersigned, hereby consent to my child/ren, the above named, participating at The Portsea Camp, including involvement in potentially dangerous and life threatening recreational activities including high ropes course, Giant Swing, initiative activities and waterbased activities. In the event of an accident or emergency, I authorise the servants and agents of The Portsea Camp to obtain for my child/ren all the necessary medical and dental assistance and treatment as may be required. I agree to reimburse The Portsea Camp and pay all expenses incurred in relation to such assistance and treatment. I hereby release to the full extent permitted by law The Portsea Camp and its servants and agents from all claims and demands of every kind for any accident harm or loss which my child/ren may suffer or that I may suffer as a result of my child/ren participating in The Portsea Camp. I hereby indemnify The Portsea Camp and its servants and agents to the full extent permitted by law for any loss, damages, expenses, claims, actions and suits brought for and on behalf of my child/ren and arising out of or in any way connected to The Portsea Camp.

Signature _____________________________ Name ________________________Date ___ / ___ / ___

Consent for photography / video:

I consent to The Portsea Camp using photographs or videos of my child/ren in any legal way that it thinks fit, including publication or dissemination in any medium. I acknowledge that The Portsea Camp is the owner of any intellectual property in such images and any material (including promotional material) created using the photographs or videos. I waive any moral rights that I might have in my child/rens name/s, his/her/their images, photographs, or any captions relating to the photographs or videos. I release and forever discharge The Portsea Camp and its servants and agents against all proceedings, claims and demands by me in respect of any matter or thing, including loss or damage of any kind sustained or likely to be sustained by me as a result of, arising out of, or in connection with, any use by The Portsea Camp of the photographs or videos and any captions relating to them. I acknowledge that I have no right to require payment for, or participate in, any proceeds arising out of the use of the photographs or videos. All inappropriate photography including photos taken in bedroom, close-ups of sensitive body areas and photos that in any way demean the child ARE NOT PERMITTED. All children receive a free CD of camp photos.

Signature _____________________________ Name ________________________Date ___ / ___ / ___

Ensuring your privacy:

The Portsea Camp is concerned to ensure that your child's privacy is protected. Except in an emergency, we do not divulge any information on children to a third party without the prior consent of a parent or guardian. All information on children provided to children's carers at camp is destroyed immediately following the camp except for a single copy accessible to limited camp personnel as required by law.



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