Register Camper Country Madness 2020 Camper Registration Step through the registration process. Step 1 of 6 - Registration 0% Age Group*Age under 1818 or olderCamper's Role*I am a camperI am a leaderPayment Option*The 2020 registration fee is $80 per person, or $50 per person when more than 1 in your family is attending camp. For payment, please use the payment option on this website, once registration is completed.I understand that registration will be $80 or $50 per person, as described above. Name* First Last Gender*FemaleMaleAddress* Street Address Address Line 2 City/Town State Postcode Date of Birth* Date Format: DD slash MM slash YYYY Email* Phone*School year (in 2019)Home Church (if any)Share room with(person or group, if you have a preference) Parent/Guardian Name* First Last Parent/Guardian Phone*Alternative PhoneEmergency Contact Name* First Last Emergency Contact Phone* Medicare Number*Position on the card*Please enter a number from 1 to 9.Private Health FundFund Member #Last Tetanus Booster Date Format: DD slash MM slash YYYY Doctor Name & PhoneOther relevant informationAllergiesPlease list the specific details of any allergies you/your child has (e.g. insect stings, food, band aids, first aid treatments, drugs or other)Medical ConditionsPlease list the specific details of any medical conditions or illness you/your child has (e.g. asthma, epilepsy, hyperactivity, heart problems, diabetes or other)Additional NeedsPlease list the specific details of any conditions which require special attention or consideration from us (e.g. low vision, hearing loss, ADD or ADHD, behaviour issues, formal counselling situations, bed wetting, sleep walking or other)MedicationsName and dosage of medications which may be required during activities (e.g. Ventolin, epi-pen or other) All medications must be personally administered. Note: non-prescription medications such as paracetamol (eg: Panadol) will not be provided or administered.Dietary RequirementsPlease list the specific details of any dietary requirements you/your child has (including food allergies and intolerances)How is the camper getting to and from camp, and under whose care?* Custody MattersPlease list the relevant details of any legal or custody matter or order (current or pending)Swimming Ability*How well can you/your child swim?Cannot swimFair SwimmerGood swimmerGeneral RestrictionsPlease list the specific details of any activity in which you do not wish you/your child to participate, or that could cause anxiety to you/your child. RELEASE STATEMENTPlease read each item below and indicate your agreement (Yes) or disagreement (No) for each. If the camper is <18 years of age, this must be completed by a parent/guardian with suitable authority. If the camper is 18+ years of age, these answers must be provided by the camper (read child/ren as self).I confirm*that the information provided in this document is true and correct. Yes No I warrant*that I have power to provide this information and agree to inform the Camp Directors of any change to these details.YesNoI consent*to my child/ren becoming a member of and taking part in the overall activities of the abovementioned program.YesNoI understand*that if urgent medical attention is needed, every effort will be made to contact the persons listed on this form. In the event that I cannot be contacted in an emergency, I give my permission for my child/ren to receive medical treatment as deemed necessary by the leaders of the camp.YesNoI consent*to information about my child/ren being collected and used for the running of activities and reporting of incidents and accidents. YesNoI give my permission*for my child/ren to be transported in church vehicles or private cars arranged by the leaders on occasions when it is necessary.YesNoI give my permission for my child/ren*to be photographed, videotaped or recorded. I understand that the Church will not disclose personal or identifying details of me or my child/ren, to any other person, body or organisation without my permission or it is authorised or required by law. I understand that this material (including name and congregation or activity) may be used and disclosed for the following purposes: (1) In promotional or information materials produced by the camp (2) In worship and materials prepared by or for the camp (3) On the Church’s website and social media platforms (4) As otherwise permitted or required by law.YesNoI warrant*that I will advise the camp directors of any change of circumstances that would affect the Church’s care of my child/ren or changes to the details of this form.YesNoI warrant*that I will advise the activity leader of unique circumstances regarding my child/ren that may affect their participation in the camp.YesNoCommentsThis field is for validation purposes and should be left unchanged.
