Pre-registration form for Lady Northcote Camp

Lady Northcote Recreation Family Day Escape will be held on:

Wednesday 20/04/22 10am - 4pm.

The event will be held at Lady Northcote Recreation Camp:

1273 Glenmore Rd, Glenmore VIC 3340.

This event is for Vietnamese Families who have a child with a disability and are residing in Melbourne's northwest metro regions.

This event will have a capacity limit of 20-25 families, so pre-registration is essential.

The Family Escape day will include 3 activities run by YMCA. Extended Families' staff will also be present to help support families. Please identify which activities your family is interested in below. The most popular activities will be chosen.

Eligible requirements:

Family from a Vietnamese cultural background
At least one parent/ guardian in attendance with a child with a disability and siblings
All children attending must be under 18 years of age
Parents and participants (age of 12 and over) must be double vaccinated against COVID-19 or have valid medical exemption

Social distancing will be observed at this event.

Participants must wear a mask always especially when indoors or when 1.5m distance cannot be observed. Masks must be worn by children grade 3 and up and parents. Masks can be pulled down during strenuous physical activity outside.

The escape day is free of charge for families.

Morning tea, lunch, and afternoon tea will be provided.

If families are unable to make their to and from the location independently, a bus will transport families to the event. However, spaces on the bus are limited.

After pre-registering your interest, Extended Families will send you an Enrolment Application Form.

Name of Parent/ Legal Guardian attending *

First Name Last Name

What languages are spoken by Parent/ Guardian? (Can tick more than 1) *

Vietnamese English Other

Is an interpreted required when communicating with English-speaking staff? *

Yes No

Parent/ Guardian contact number *

Parent/ Guardian email *

example@example.com

Address of parent/ guardian *

Street Address

Street Address Line 2

Suburb

Postal / Zip Code

Is parent/ guardian double vaccinated against the COVID-19 virus? *

Yes No

How many members of your family will attend the event? (Please note only immediate family is eligible to attend.) *

(Click on the downward arrow to see options. Number includes child with disability and other family members.)

What is your relationship to children attending the event? *

Father Mother Legal guardian Siblings over 18 years old Other

Will second parent/ guardian be attending the event? *

Yes No

Is second parent/ guardian double vaccinated against COVID-19 virus?

Yes No

Does your family require transport to and from the event? *

Yes No

Name of young person with a disability attending *

First Name Last Name

Gender: *

Male Female Other

Participant's Date of Birth *

Date

What languages does the participant speak? *

Vietnamese English Other

Is an interpreter required for participant when communicating with English-speaking staff? *

Yes No

Is young person double vaccinated against the COVID-19 virus? *

Yes No

What is the participant's primary disability? *

Does the participant experience any secondary disabilities? *

Does the participant experience any health or medical issues? If yes, please specify. *

Does the particiapant have any of the following Plans in place? (The program will require a copy of any plans prior to participantion)

Asthma Emergancy Plan Medical Emergancy Plan Epilepsy Management Plan Behaviour Support Plan

Does the participant currently attend school or day program?

Special School Mainstream / Private / Catholic / Buddhist School Day Program Other

Please note places for the Lady Northcote camp are now full. However, if you would like to be placed on the waiting list, please go ahead and complete the form below. If a space becomes available, we will contact you and let you know.