Which camp do you wish to attend?*

Name*

First

Last

Date of Birth*

dd/mm/yyyy

Address*

Address 1

Address 2

City

Province

Postal Code

Country

Home Phone Number*

Mobile Number

Work Phone Number

Email*

I would like to be in the same unit as

Medical Information

Please answer the following questions in relation to the applicant named at the top of this form

Emergency Contact Name*

First

Last

Emergency Contact*Prefered Phone Number

Emergency ContactAlternative Phone Number

Medicare Number (Including position number on card)*

Other Health Care Fund Details

Do you suffer from heart problems?*

If yes please give details

Do you have Respiratory Problems*

If yes please give details

Do you suffer from Travel Sickness?*

Do you suffer from Phobias?*

If yes please give details

Have you had a recent operation*

If yes please give details

Have you suffered from a recent illness?*

If yes please give details

Do you suffer from migraines?*

Do you suffer from Blackouts?*

Do you suffer from Fits, Epilepsy etc?*

If yes please give details

Do you suffer from Asthma?*

Are you a Diabetic?*

If yes please give details

Are you restricted from participating in any activities?*

If yes please give details

Do you wet the bed?*

Are you on a special diet?*

If yes please give details

Do you have a disability?*

If yes please give details

Do you require medication?*

If yes please give details

Do you have any drug reactions?*E.g. To penicillin, morphine, tetanus, etc

If yes please give details

Do you suffer from any allergies?*E.g. bee stings, nuts, animals, etc

If yes please give details

Can you swim?*

Date of Last Tetanus Booster*

dd/mm/yyyy

This box is for any extra information or notes that you may haveThis may be in relation to medical issues or payments

COSTS OF CAMP

1st Child from Family $220

2nd Child from Family $210

3rd Child from Family $200

Additiional Costs

Bus Trip $30

Rocketry $30

Please list any other sibblings that are attending Summer Camps this season*

Location of Bus pick up / drop off*

I would like to do Rocketry for an additional cost of $30*

Payment Details

Credit Cart Type*

Credit Card Number*

Credit Card Expiry Date*

Name as appears on Credit Card*

Consent & Release

I declare that I have read the information regarding Summer Camps. I also understand that it is a condition of participation to accurately complete the Medical Record.

In the event of accident or illness I authorise the Camp Director to consent, where it is impractical to communicate with me (parent/guardian), for my child to receive an x-ray examination, anesthetic, medical, surgical or hospital treatment as may be deemed necessary by a licensed physician and/or surgeon. I also authorise to engage such treatment. I agree that if my child suffers any injury or illness, the organisers can arrange medical treatment and emergency evacuation services, as the organisers deem necessary for my childs safety or well being.

I agree to pay the appropriate fees for such and any other emergency transportation costs, which may be required. I agree to meet the expense of my child being returned home and then rejoining the group (if fit to return). I understand that such an arrangement may be necessary due to illness, injury, or if, in the opinion of the Camp Director, non-cooperation of any description or the inability to meet the rigors and requirements of the activity.

In signing this document I am aware that there may be some risks involved for my child and choose to allow them to participate based on this understanding. I agree to accept this risk, and release to the full extent permitted by law, the SEVENTH-DAY ADVENTIST CHURCH (South Queensland Conference) LIMITED and its employees and agents from responsibility for any injuries which my child may suffer as a result of their participation in the programs and activities at Summer Camps.

I agree for my child to attend on this understanding.

Parental / Guardian Approval*in relation to the Consent & Release

Media Usage Approval

I understand that this event will be captured by both still photography and video footage. I give permission to the South Queensland Seventh-day Adventist Department of Youth Ministries to use this material for future promotional purposes.

Parental / Guardian Approval in relation to Media Usage*

Terms & Conditions

CANCELLATIONS: A fee of $50.00 per person will apply to any cancellations made after the application deadline. No refund will be given after November 30 unless due to medical reasons. Registration is transferable to another child in the same camp or another camp (If space permits).

PROCESSING OF APPLICATIONS: We are unable to process your registration without full details and payment (Unless prior arrangements have been made). Please note that there are limited places available so it is wise to get your application in early

TRANSPORT: Will be leaving NCC and BAC at 9am on the applicable Summer Camp starting date. Please ensure you are there at least 15 minutes early to avoid missing the bus. You will need to tick the appropriate box on the application from and pay the additional $30 fee per child.

REGISTRATION: Will commence on the applicable Summer Camp starting date from 10.00am till 11.45am

FIRST MEAL: Will be lunch on the applicable Summer Camp starting date

All information is correct at time of printing. Summer Camp organisers reserve the right to change any of the published details if deemed necessary.

I have read and understand the terms and conditions above*

Yes

Address

Address 1

Address 2

City

State

Postal Code

Country

Snail Mail*

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