Which camp/s would you like to be a staff member at?*Please be aware that we may not be able to assign you to all the camp/s you select. To be a staff member for Junior Camp you must be at least 16 years old. To be a staff member at RC4KC or Teen Camp you must be at least 18 years old.

Junior Camp Dec 13-19 2010

RC4KC (Rotary Club for Kid Carers) Jan 3-7 2011

Teen Camp Jan 10-16 2011

Name*

First

Last

Gender*

Male

Female

Date of Birth*

Address*

Address 1

Address 2

City

Province

Postal Code

Country

Home Phone Number*

Mobile Number

Work Phone Number

Email*

SHARE YOUR THOUGHTS

Have you been a Staff Member at a Summer Camp before? *

Yes

No

What role/s have you held at previous Summer Camps?

What skills/experience can you bring to Summer Camps? *

Reference - Please list the Name and Phone Number of either your Church Pastor, Elder, Youth Leader or Pathfinder Leader*

Blue Card*

Yes

No

Blue Card Number

Summer Camp Licences/CertificatesPlease indicate what current certificate/s or licence you hold.

Bus Licence

Boat Licence

First Aid Certificate

Bronze Medallion - Duke of E

Life Guard Certificate

Food Handling Certificate

Activities*Please indicate what areas of activities you are interested in (licence permitting)

Nurse/First Aider

Bus Driver

Canoe Instructor

Lifeguard

Camp Mum

Theme tea organiser

Boat Driver

Ropes Instructor

Archery Co-ordinator

Counsellor

Camp Dad

Kitchen Staff

Craft Coordinator

Waterfront Coordinator

General Auxiliary Staff

Music Team Coordinator

Music Team Member

Worship Team Coordinator

What size shirt do you wear? *

COSTS OF CAMP

Per Camp $75

Payment Details

Payment Type*If paying by cash or cheque please send payment ASAP. Please make cheques out to 'Seventh-day Adventist Church (Sth Qld) Conference.

Cash

Cheque

Call SQ Youth and provide them with my credit card details

Medical and Consent Details

Do you consent to appropriate use by us of your photograph in/on the following. Please tick only those you consent to. If you do not consent to any please send the Youth Department a photograph of yourself so that we can identify you and ensure we do not use your photograph. All photos received will be kept strictly confidential.

Website

Photo CD (provided to participant's at the end of camp)

Focus/Newsletter

Brochure/Flyer

None of the Above

Do you have any special dietary requirements? *Please note all food provided is Vegetarian.

Yes

No

If so, please list them below (we will endeavour to meet these requirements, and will contact you if there are any problems).

Can you swim?

No

Fair Swimmer

Good Swimmer

Are you subject to sleep walking?

Yes

No

Emergency Contact*

First

Last

Relationship to You

Phone Number

Are there any conditions which require special attention that we should know about? e.g. hearing or sigh impairment, ADD or ADHD, behaviour issues, formal counseling situations or any other. Please list below.

Insurance Provider

Membership Number

Medicare Number*

Please note that in regards to non-prescription medications such as paracetamol, it is our policy that team leader members do not porvide medications. Will you need to take any tablets or other medications during the course of the program?

Yes

No

If yes, please list the medication. Note: If an epipen may be required it must be carried on the person at all times. Any other medication will need to be stored in a locked storage container or handed in to the Camp Nurse/First Aider immediately on arrival.

Have you been taken off any medication recently?

Yes

No

If yes, please give details

What is the year of your last tetanus injection?

Have you previously broken/fractured any bones?

Yes

No

If yes, please give details.

Please indicate if you have had any of the following

Asthma

Appendicitis

Bronchitis

Chicken Pox

Diabetes

Ear Infections

Epilepsy

Fits/Convulsions

Faint/Dizziness

Glandular Fever

Hyperactivity

Hypoactivity

Heart Problems

Measles

Mumps

Pneumonia

Tonsillitis

Allergy-Foods

Allergy-Animal

Allergy-Other

Details

Please indicate if you currently have any of the following?

Asthma

Diabetes

Ear Infections

Epilepsy

Fits/Convulsions

Faint/Dizziness

Glandular Fever

Hyperactivity

Hypoactivity

Heart Problems

Allergy-Foods

Allergy-Animals

Allergy-Other

History Details

In attending the program, you consent to your participation in a range of general sporting and recreational activities. If specific risk-oriented activities are included, the program director will have informed you of these. Are there any specific activities that you do not wish to participate in? *

Yes

No

If so, please specify:

Consent & Release

I am aware, in agreeing to my participation in this program, that certain elements of the program could be physically and emotionally demanding. Furthermore, I understand that certain inherent risks and dangers exist in the activities in which I will be participating. I acknowledge that while the organisation and its leaders will make every reasonable effort to minimise the exposure to known risks, all hazards and dangers associated with these activities cannot be foreseen or may be beyond the control of the organisationn, its leaders and staff.

In the event of an emergency where my nominated contact people are unavailable:

- I authorise the leaders to obtain medical advice and/or assistance which they deem necessary.
- I further authorise qualified practitioners to administer anaesthetic if required.
- I accept all operation, blood transfusion and/or anaesthetic risks involved in the event that such procedures are deemed necessary.
- I accept the responsibility for payment and agree to pay medical, transport and any other related expenses.
- I confirm that the information contained in this application is true and correct.
- I agree to inform the leader of any change to these details.

Do you consent to the above? *

Yes

No

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Summer Camp Staff Application 2010