Red Youth Camp Registration Form (Youth)

Youth Camp Registration Form
Youth's Name*

First NameLast Name
Date of Birth*

DayMonthYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian/Emergency-contact Full Name*

First NameLast Name
Parent/Guardian/Emergency-contact Mobile Number*
Please enter a valid phone number.
Parent/Guardian/Emergency-contact Email*
example@example.com
Is this the first time your youth has been away on camp?*

YesNo
CONFIDENTIAL

This report is compiled to assist in the case of any medical emergency and to ensure appropriate care and safety are taken with your youth whilst on camp. All information is held in confidence and these forms are destroyed after the camp.
Is your youth currently taking any tablets/medication?*

YesNo
Please state the name of medication, the dosage and the reason for taking:
All medicines must be handed to the first aid leader when arriving at camp, with your youth’s name, the dose to be taken and when it should be taken.
(These will be kept by the designated first aid leader and distributed as required.)

Please do not allow your youth to be in possession of any medicine whilst on the camp.
Name of Family Doctor*
Phone Number of Family Doctor*

Area CodePhone Number
Medicare Number*
Include youth's number
Medical/Hospital Insurance Fund:
If applicable
Ambulance Cover Membership Number:
If applicable
Does your youth suffer from any of the following?

BedwettingDizzy SpellsSleep WalkingTravel SicknessDiabetesMigraineAsthmaBlackoutsFitsHeart ConditionOther
Please provide further details:
Is your youth allergic to any of the following?

PenicillinOther medicationsPeanutsGlutenEggOther
Please provide any further details:
Does your youth have any special dietary requirements?
Does your youth have any special needs or have any recommended special care?
Date of last tetanus immunisation*

DayMonthYear
Date
Consent to Medical Attention

Please sign the statement below which is required for all youth attending camp.

I authorise the leader in charge of the camp to consent on my behalf, where it is impracticable to communicate with me, to my youth receiving such medical or surgical treatment as may be deemed necessary and to administer such first aid as the leader in charge may judge to be reasonably necessary.
Signature of Parent/Guardian*

Clear
Are you paying for multiple youth?

YesNo
Camp Payment Options – $220

Credit CardDirect Debit

Direct Debit

$200 p/youth

Name: Red Church
BSB: 033-112
Acc: 386-850

Description: Youth Camp – [family name]
Name: Red Church
BSB: 033-112
Acc: 386-850

Description: Youth Camp – [family name]
Should be Empty:

Youth Camp Registration Form

Payment Methods