Highland Home Kids Camp Campers Registration Form

Camper Information

Camp Dates *

Name *

First Name Last Name

Birth Date *

Month Day Year

Age *

Gender *

Male Female

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

If possible, share a cabin with

Do you need an OSCAR subsidy form? This will be emailed to you.

Yes No

Payment Information - Please pay your fees in to:

Highland Home Christian Camp

01-0754-0006660-04

REFERENCE: Please use your child's initial & surname eg - J.Smith

Please use family surname for families with multiple children attending

Early Bird: $195 - to be paid by Sunday 15 December 2019

Standard Rate: $225 - payment received from Monday 16 December 2019

Please note - if you are registering a child through a government agency, the rate is $245.00 per child and no discounts will apply. Please send all P/O's to: highlandhome@xtra.co.nz

Discounts may apply to families with multiple children attending - please see your confirmation email for this rate.

Parent/Guardian Information

Name *

First Name Last Name

Home Number *

Area Code Phone Number

Cell Number *

Area Code Phone Number

E-mail *

Emergency Information

Please use a different contact from above

Emergency Contact's Name *

First Name Last Name

Relationship *

Phone Number *

Area Code Phone Number

Alt. Phone Number *

Area Code Phone Number

Doctors Name *

Doctors Phone Number *

Transport Information: Who will drop off and pick up your child from camp? *

Other Information: Please give us any information to assist camp staff to care for your child and any names of people who have restricted access to the camper. *

Does the camper have any dietary requirements, allergies, chronic illness, or medical conditions that staff need to be aware of. Will any treatment be required while at camp? If yes, please describe. *

Informed Consent and Acknowledgement

I declare that the details on this form are true and correct. I have read, understood and accepted the parents & guardians notes. I will update HH if any of these details change.

All fees are due 14 days prior to camp date or your registeration may be forfeited.

If you are applying for a OSCAR subsidy, we require a pre-payment of $195.00, 14 days prior to camp commencing. A refund may apply depending on the OSCAR subsidy paid to camp.

For Terms and Conditions - please visit our website www.highlandhome.co.nz or our facebook page 'Highland Home Christian Camp'

I hereby give approval for my child to participate in any and all activities prepared by Highland Home, on and off site, during Kids Camp.

I agree they will abide by camp rules and that I will pay for any willful damage caused by my child.

I understand that if my child is sent home early due to behavioural issues, a refund will not apply.

Making a Formal Complaint - I understand that I can make a formal complaint by downloading the 'Complaint Form' from: https://highlandhome.co.nz/wp-content/uploads/2019/10/Complaint-Form.pdf and following the instructions on the form.

I authorise Highland Home to send me information about future camps and for any photos or videos taken of my child during camp to be used for publicity purposes if required.

I authorise Highland Home to present information regarding my child's registration and involvement of Kids Camp to governing agencies such as MSD or Oranga Tamariki for auditing purposes.

Privacy Statement - I understand this information will not be shared with other persons or agencies without the consent of the parent/cargiver, except where there is a concern about safety and welfare of a child and as advised by the Police, Oranga Tamariki and or MSD.

In case of injury to my child, I hereby waive all claims against Highland Home. including all leaders and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners, trusees and managers and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all adventure activities. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.

Required *

Yes, I accept informed consent and acknowledgement informaton

Medical Release and Authorization

While all care is taken in the administration of medication to campers, neither Highland Home trustees, management, staff or any other persons associated with the camp will be held responsbile for any error, adverse effect or other problems associated with or caused by the administration of any medication given to your child.

In case of a medical emergency I give Highland Home permission to seek medical help as required after first trying to contact me using the phone numbers given above. As Parent and/or Guardian of the named camper, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to Highland Home and its affiliates including Trustees, Managers and Programme Leaders to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the camp.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

Required *

Yes, I accept the medical release and authorization information

Confirmation

BY ACKNOWLEDGING AND RELEASING THIS FORM, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Electronic Signature of acceptace - Full Name *