Summer camp 2010 form by alendar

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									                         Unified 2010
                 NC Youth Alive Summer Camp
Step One – Group Details
Are you a part of a group?     Yes          No 
Group/Church Name: _____________________________________________________________________________

Group Leaders Name: _____________________________________________________________________________

Step Two – Personal Details
First Name: _________________________________ Surname: ___________________________________________
                                                             th
Date of Birth: ____/____/_____ (must be 12 years old by 5 Jan 2010 to attend)

Gender:            Male       Female 

Step Three – Contact details
Address: _______________________________________________________________________________________

Suburb: _____________________________________State: ___________________Postcode: __________________

Phone (Hm):__________________________________Phone (Mob): _______________________________________

Email: _________________________________________________________________________________________

Step Four – Church Details
Church Name: ___________________________________________________________________________________

Denomination: ___________________________________________________________________________________

Youth Leader/Pastors Name: _______________________________________________________________________

Step Five – Emergency Contact Details (Required Information)
Emergency Contact Name: _________________________________Relationship to Camper: ____________________

Phone Numbers (Hm): ____________________ (Wk): _____________________ (Mob):________________________

Medical treatment consent:
I give permission for North Coast Youth Alive authorised staff and volunteers to obtain emergency medical hospital or
ambulance assistance at any time they consider necessary. I understand that every effort will be made for myself to be
notified before instituting such procedures. I acknowledge that I will be liable for any medical/hospital/ambulance
expense incurred in the treatment of my child. I also understand that while every reasonable precaution will be taken to
ensure the protection of my child, I herby release and hold harmless North Coast Youth Alive Authorised Staff and
volunteers from any and all liability in the event of an injury, accident or misfortune, damage or loss that may occur to
my child and their property while present at this North Coast Youth Alive Event.

Involvement Consent:
I give permission for the above child (or myself, if over 18) to participate in activities they (I) may choose while attending
this North Coast Youth Alive event. I agree and understand that North Coast Youth Alive reserves the right to exercise
its discretion to refuse to register any person upon medical and/or other health grounds without providing a detailed
reason for doing so.

Medical Consent
Paracetamol Consent:
 By ticking this box, I give consent for first aid staff to administer paracetamol to my child if deemed necessary.

Parent/Guardian name (or own name if over 18): ________________________________________________________

Signature: __________________________________ Date: ____________________ Phone: ____________________
Step Six – Payment Details
 $150      Early Bird Special only available until 19th Dec 2009
                                           th         st
    $175           Early registration 20 Dec - 31 Dec 2009
                                       st  th
    $200           Full registration 1 - 5 Jan2010

Step Seven – Merchandise orders
Camp T-Shirt Cost: $20 each.

 Girls Size 8                                                               Guys Size XS
 Girls Size 10                                                              Guys Size S
 Girls Size 12                                                              Guys Size M
 Girls Size 14                                                              Guys Size L
 Girls Size 16                                                              Guys Size XL
 Girls Size 18

Total cost of Merchandise Order: __________ x $20 = __________

Step Eight – Total Payment
Registration $__________ + Merchandise $____________ = Total $_____________

Step Nine – Payment method
 Cash (please do not post cash)          Cheque/Money Order North Coast Youth Alive
Credit Card:
 MasterCard         Visa        Bankcard         AMEX

Card holders name: __________________________________________

Card Number: _ _ _ _ /_ _ _ _ /_ _ _ _ /_ _ _ _

Expiry Date: _ _/ _ _ /_ _ (Will appear on statement as LifeHouse Church)
Phone number of card holder: ____________________________

Total Amount: $__________________

Cardholders Signature: _____________________________________

Step Eleven – Conditions
GST: The registration price does not include GST as it is considered a ‘Religious Service’. Should you require a tax receipt for your
records, please photocopy the registration form prior to returning it to us.
Refunds: No refunds will be paid, however you may transfer your registration to another person, subject to this registration form
being completed by the proposed registrant, and the consent of North Coast Youth Alive. All transfers must be made to North Coast
Youth Alive in writing.
Video/Photo/Privacy: I being the parent/guardian give consent for my child to be captured in any video or photography at
Spring Camp and I understand that this material may be used for future promotional purposes.

 I have read and accept these conditions. (Please note: Registration will not be accepted unless this box is ticked)
Registrant
Print Name: ____________________________ Signature: __________________________ Date: _______________
Parent/Guardian (must be completed for registrant under 18)
Name: ________________________________ Signature: ___________________________ Date: ______________


Step Ten - Department of Sport and Rec forms
Please make sure that the relevant Department and Recreation forms are filled in and signed and
sent with this form to:
        North Coast Youth Alive
        C/- Lifehouse church
        25 Alison St Coffs Harbour NSW 2450
If you need extra copies of forms they can be obtained by email: joe@ballinacc.com.au or visit the
website: www.northcoastyouthalive.com details of what to bring will be posted on this website
closer to the camp date.
                                                                                                             NSW Sport and Recreation


                        Medical and consent form
                                                                                                                                                 Child
  Participant details
Surname                                                              Given names


Address



                                                                                                                         Postcode
Name of school                                                       School year            NSW Sport and Recreation customer no.


Date of birth                        Age               Male      Female      Are you of Aboriginal or            Are you or your parents from a
            /            /                                                   Torres Strait Island descent?       Non-English speaking background?
                                                                             (statistical purposes only)         (statistical purposes only)
                                                                                    Yes          No                   Yes          No


  Program details
Program type (please circle)                                                          Program number (if known)
      School / Holiday / Community / Sporting / Recreation / Other

Venue                                                                         Program dates (from)                    (to)
                                                                                            /           /                          /             /



  Parent/guardian details
                                              Mother/guardian                      Father/guardian                    Guardian/other contact
 Full name of parent or guardian

 Home phone

 Work phone

 Mobile

 Mobile

 Mobile


  Special/Dietary needs
Please identify any special needs or requirements not listed above      Has he/she had the Combined Diptheria Tetanus Toxoid booster injection?
(eg. diet, wheelchair access etc.)

                                                                            Yes             No    Year



                                                                        Has he/she been immunised against measles?

                                                                            Yes             No        Year


  Swimming ability
                                                                                                                                               continued over…
     Strong – 50 metres unaided             Average – 25 metres unaided                   Poor – 10 metres unaided                     Non-swimmer
  Medical information
Does the participant suffer from any of the following?
     Any allergic condition                                           Skin condition                                                    Diabetes
     Epilepsy, fits or blackouts                                      A disability or chronic illness                                   Asthma (include asthma plan)
     Attention Deficit Disorder (ADD/ADHD)                            Sleep walking                                                     A current illness eg. flu
     Bed wetting                                                       Behavioural problems                                             Other
If yes to one or more, please give details (attach sheet if required)




Medicare number                                                 Health care card number Pensioner health benefits card                   Pharmaceutical benefits concession card
                                 Position number
                                on Medicare card
Private health insurance fund                                         Number
                                                                                                                   Do you have ambulance cover?                          Yes            No


  Current medication
                                Time and Dosage – Please specify exact time of medication

                                Breakfast                        Lunch                            Dinner                          Before bed                      Other

 Name                           Time            Dose             Time            Dose             Time            Dose            Time            Dose            Time              Dose

 eg. Bricanyl                   8am             2 puffs         12.30pm         2 puffs         6pm             2 puffs         8pm             2 puffs




Notes:
1. Scheduled medication must be provided in the original container (as required by legislation).
2. All medications will be collected and administered by staff, unless notified in writing to the contrary.
3. Staff will supervise and register the taking of all medication.

Risk waiver                                                                                      Privacy statement
Program name                                                  Program date                       The NSW Department of Tourism, Sport and Recreation of 6 Figtree Drive, Sydney
                                                                                                 Olympic Park, NSW 2127 will collect and store the information you voluntarily provide to
                                                                       /          /              enable processing of enrolments for Centre programs. The information will be provided to
                                                                                                 instructors of the program and their supervisors, where necessary, and you consent to
                                                                                                 this disclosure. If you have been asked for information regarding Aboriginal and Torres
Venue                                                                                            Strait Islander descent and cultural background, this information is voluntary and is being
                                                                                                 compiled for statistical purposes only. Any information provided by you will be stored on a
                                                                                                 database that will only be accessed by authorised personnel and is subject to privacy
                                                                                                 restrictions. The information will only be used for the purpose for which it was collected.
                                                                                                 Any information provided by you to the department can be accessed by you during
I agree to my child's/ward's attendance at the above mentioned program.                          standard office hours and updated by writing to us or by contacting us on 13 13 02.
In the case of an emergency, I authorise the program staff, where it is impracticable to
communicate with me, to arrange for my child/ward to receive such medical or surgical            Media consent
treatment as may be deemed necessary. I also undertake to pay or reimburse costs                 Strike out whichever does not apply.
which may be incurred for medical attention, ambulance transport and drugs while my
child/ward is enrolled with the program.                                                         I agree to allow NSW Sport and Recreation to use my child's/my ward's name and any
                                                                                                 photographs, sound and film recordings taken of my child/my ward at this program for
I understand that although TSR and its service providers attempt to minimise any risk            the promotion of the department's services and initiatives to the media and to the
of personal injury within practical boundaries, accidents do happen and all physical             general public.
activities carry the risk of personal injury. I acknowledge that there is an inherent risk
of personal injury in physical activities that will be undertaken as part of this program.
                                                                                                Full name of parent or guardian
Full name of parent or guardian

                                                                                                Signature                                                    Date
Signature                                                                                                                                                               /       /


Date
          /        /                                                                                                               For more information call

                                                                                                                                                   13 13 02
                                                                                                                                        www.dsr.nsw.gov.au
October, 2005                                                                    For deaf, hearing or speech impaired people TTY (02) 9006 3701

								
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