Light It Up Camp Application Form - York St Church of Christ

Light it up youth camp
16-18 march 2012
Camp accacia, halls gap
HOW TO REGISTER:
Post application and full payment by
Sunday 11 March
“Light It Up Youth Camp”
York St Church of Christ
410 York St, Ballarat, 3350
OR
Hand in at Switch Youth on Friday Night or Sunday night church
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A separate application form is required for each camper. This
form may be photocopied if required. Parent/Guardian must
complete the following pages.
1. INFORMATION FORM
Camper’s name:
……………………………………………………………
Address:
………………………………………………………………………
……..………………………………………………
Postcode: …………………
Phone: (
) ………………………………………...
Date of Birth: ……………………………………...
Email: ……………………………………………….
Year Level......................
School............................................................
Dietary/Requirements...........................................................
...........................................................................
Medical
Conditions..............................................................................
............................................................................
......................................................................................
Has he/she been fully immunised against tetanus? Yes
or No
2

Date of last injection/ booster:
………………………………………….
Is your child allergic to penicillin, or any other
medication, insect, plant, food etc.?
Details (include
treatment)……………………………………………….
……………………………………………………………..............
.................................................................................................
................................................................
Swimming ability:
Non swimmer / weak / average / strong
Medicare No: ……………………………………
Expiry Date: ………………………………………
Private Health Fund: ………………………………………
Membership Number: ………………........
Emergency 24 hr Contact Details
Name of Parent / Guardian _________________________
Phone: (home) ____________(mobile)_________________
Second Emergency Contact Person, during camp:
Name __________________(relationship to camper)___________
Phone (home)_____________(mobile)_________________
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Activity/ Medical Statement:
This section is to be signed by parent/guardian if
application is for campers under 18 years of age. If over
18 years of age, campers are required to sign this
statement.
By signing and returning this form, I consent to the following:
I consent to the camper participation in all activities during
camp. I understand that York St Church of Christ’s leaders and
staff will take all reasonable care of the campers whilst at
camp. I agree to collect the camper in the event of a dismissal
from camp. I authorize the camp director in charge, where it is
impractical to communicate with me to consent to emergency
medical arrangements on my behalf as deemed necessary by
a qualified medical practitioner. (Such consent includes
anesthetic, blood transfusions and operations.) I give permission
for the camper to be contacted by York St or a representative
of York St Church of Christ after camp. I also give permission for
camper’s image to be used in any York St publication, media
print, or on the web page.
I agree / do not agree (Please circle) to the camper being
administered to paracetamol, when necessary, in
recommended doses.
Parent/Legal Guardian OR Over 18 camper signature:
Print Name _____________________________________
Signature _______________________ Date ___________
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PAYMENT INFORMATION
Payment Type: February Early Bird: $130 pp March: $140pp
Cash
Sibling Discounts: 1 st Youth $130, 2 nd $120, 3 rd $110
(Camp price includes accommodation, all food and bus trip)
Cheque (Made payable to York St Church Of Christ)
Credit Card Authority Please debit $______ to my
Bankcard Visa Mastercard
Card Number ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Name on Card ______________________________
Expiry Date_______________
Signature __________________________________
DEPOSIT, CANCELLATION AND REFUNDS
Each application must be accompanied by a
$30 non refundable deposit.
Any cancellations made in the final week before camp will
forfeit all monies paid. The only exception will be in cases of ill
health or other unforeseen circumstances. All refunds are at the
discretion of the Youth Pastor.
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