IGNITE Youth Camp Registration Form

IGNITE Youth Camp Registration Form
WHO ARE YOU FOLLOWING?

Date:
10:00am, Monday 30th September – 3:30pm, Friday 4th October

Location:
Don Bosco Camp - 52/62 Dromana Parade, Safety Beach, 3936

Cost:
Camp Registration $315
*Early Bird Price $290 (Before Sunday 28th July)
**Registrations recieved after Sunday 8th September will inquire a $15 late fee**

Contact Bre Wilkinson for more information
b.wilkinson@gwac.org.au
0419 930 097
Participant Information
Participant Name *

First Name Last Name
Birth Date *

Day Month Year
School Year *
eg. Year 10
School Name *
Gender

Male Female

Address

Street Address
Street Address Line 2
Suburb	State
Post Code

Email *
Participant Mobile Number (if applicable)
Parent Guardian Information
Parent/Guardian Name (1) *

First Name Last Name
Relationship *
Parent Mobile Number *
Parent Email *
Parent/Guardian Name (2)

First Name Last Name
Relationship
Contact Number (2)
Parent Email (2)
Emergency Contact Information

Please include one emergency contact that is not one of the parent/guardians listed above.
Emergency Contact's Name *

First Name Last Name
Relationship *
Contact Number *
Participant Medical Information
Medicare Number *

Card Number IRN
Expiry Date *
eg. 09/2020
Doctor's Name
Doctors Phone Number

Doctors Address

Street Address
Street Address Line 2
City	State
Post Code	Country

Health/Ambulance Fund Name
Health/Ambulance Fund Number
Does the participant have any dietary requirements? *
If yes, please specify.
Does the participant have any known allergies or other medical concerns? *
If yes, please specify.
Will the participant be bringing any medication to the camp? *
If yes, please provide relevant details regarding dosage.
Who will administer the medication? *
Do you OBJECT to Panadol being given for minor pain and headaches? *
Has the participant had any recent illnesses or operations? *
If yes, please specify.
Date of last known tetanus immunisation (if known)

Month Day Year
Rate the participants swimming ability.
Is there any other information about the participant that you should disclose in order to protect their, or others, health, safety, comfort, or wellbeing?
Consent
Informed Consent and Acknowledgement

I, being the parent/guardian of the participant whose correct details appear in the "submission data" above, give permission for my son/daughter to attend the 2019 IGNITE Youth Camp at DonBosco Campsite from Monday the 30th of September until Friday the 4th of October 2019 and fully prticipate in all activities associated with the camp.
Medical Consent

I authorise the leader(s) in charge of the Glen Waverley Youth Ministry, to consent on my behalf, where it is impractical to communicate with me, to medical and/or surgical treatment, including ambulance transport as may be deemed necessary. I understand that I am responsible for the cost of all such treatment or transport for the above named participant.
Media Release and Authorisation

I understand that there may be photographs and/or video footage taken of my child during ministry activities and understand that no royalty, fee or other compensation shall become payable to me by reason of any use.
I am willing for my child to be so filmed in appropriate settings. My child is also willing for photographs and/or video footage to be taken of them. *
I am willing for these photos or footage to be used to PROMOTE MINISTRY WITHIN GWAC in a way that does not identify their name or details. This includes photos/videos shown at gathered celebrations and IGNITE. *
I am willing for these photos or footage to be used to PROMOTE MINISTRY EXTERNAL FROM GWAC in a way that does not identify their name or details. This includes printed publications, the GWAC website and GWAC social media outlets. *
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, 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.
Signature

Clear
Name of Signatory *
I understand that the participant's camp registration is NOT confirmed until my payment has been received in full within 3 business days of submitting this form. *
Should be Empty:

IGNITE Youth Camp Registration Form

Participant Information

Parent Guardian Information

Emergency Contact Information

Participant Medical Information

Consent

Media Release and Authorisation