2022 Participant Application Form

ERCNSW Winter Tuross Head Camp

Monday 11 – Thursday 14 July
Edmund Rice Camps New South Wales provide opportunities for children, young people and families to build resilience, enabling them to thrive, belong, and contribute to their communities. We have a vision for a world where all children, despite their circumstances, can have access to fun recreational opportunities which also provide the social connections and personal development to support and empower them.

Edmund Rice Camps New South Wales is a non-profit organisation that trades under Edmund Rice Services Ltd. It is governed by the Edmund Rice Community Services (ERCS) Board. Edmund Rice Camps operates as a business unit, with an Advisory Board that supports the mission, strategy and operations of the organisation.

We are a child safe organisation and we have a zero tolerance of abuse.

All information will be protected as part of our commitment to the protection of children and their families. Under no circumstances will we disclose the personal information of the children or families we assist. You can view our Privacy Statement here.

Programs Officer
Daniel Comensoli
0439 900 832
dcomensoli@edmundrice.org

Executive Officer
Bonnie Faulkner
0468 511 096
bfaulkner@edmundrice.org

It is estimated that this application will take 15-20 minutes to complete.
Times: Monday 11, TBA (Afternoon) - Thursday 14, TBA (Afternoon)
Cost: $325 per child
Ages: 5-16 years
Location: 'The Pines' Education & Retreat Centre, 36 Craddock Rd, Tuross Head
Proof of Vaccination or Exemption: Friday 1 July, 5pm
Participant Details
Full Name *

First Name Last Name
Gender *

Female Male Other
Home Address *

Street Address

Street Address Line 2

Suburb State

Post Code
Date of Birth *

Day Month Year
DD/MM/YYYY
Cultural Background
Languages spoken at home
Does the participant identify as Aboriginal and/or Torres Strait Islander? *
Are you aware of any any religious or cultural preferences or customs which may impact the child’s participation on camp? If yes, please describe below:
Camp availability (please tick all possible options for this participant)

Week 1: Monday 11 – Thursday 14 April Week 2: Wednesday 20 – Saturday 23 April
Please note: as we are anticipating a number of referrals, flexibility around program availability may assist in organising placements.

Parent / Guardian / Carer Details
Parent/Guardian/Carer's Name *

First Name Last Name
Relationship to Participant *
Parent/Guardian/Carer Address *

Street Address (or write As Above)

Street Address Line 2

City / Suburb State

Post Code
Home Phone
Work Phone
Mobile Phone
Please provide at least one contact number for parent/guardians
Next Of Kin *

First Name Last Name
Next Of Kin Relationship to participant *
Next Of Kin Phone numbers *
Preferably two numbers

Referring Agency and Worker Details
Name of Referring Agency *
Address of Referring Agency *

Street Address

Street Address Line 2

Suburb State

Post Code
Name of Agency Worker *

First Name Last Name
Agency Worker Role *
Agency Worker Email *
example@example.com
Agency Worker Phone *
Agency After Hrs Contact *
After Hours Phone Number *
This number is compulsory to fulfil our Safeguarding requirements and essential for camp safety. The contact will need to be available during attendance in the rare case the participant needs to be removed from the program. Only an Agency Staff Member contact will be accepted.
Funding
An Invoice will be raised to the person outlined under ‘Agency Details’ above. If you require an invoice sent to someone else, please provide details.
Are you aware of any other professional support agencies working with this child/family? If yes, please provide details.

Conditions of Placement (for Referrers)

Agency to Sign
CONDITIONS

Please read the following information relating to camps conducted by Edmund Rice Camps NSW. A signed copy, signifying acceptance of these conditions and a belief on the Agency’s part that the family seeking placement is suited to Edmund Rice Camps NSW's programs, must accompany each application for placement on an Edmund Rice Camps NSW program.
1. Edmund Rice Camps are coordinated by 1-2 staff member(s) and run by volunteers, principally aged 16 to 30. All volunteers are trained and screened by Edmund Rice Camps NSW, but do not all hold specific qualifications to this field. All volunteers 18 years and over hold a valid Working with Children Check.
2. All information which may affect the participation of the child in the program, including their interaction with volunteers and other participants within the age range of the camp, should be forwarded to Edmund Rice Camps NSW office at the time of referral. This includes information regarding any relevant current or recent protective concerns . All information will be kept in confidence by the Edmund Rice Camps staff and the delegated Camp Executive.
3. Edmund Rice Camps NSW reserves the right to accept or reject any application based on the best possible match between applicants and the skills of volunteers for a particular camp.
4. The caseworkers and carers contact phone number, both during business hours and after hours, is to be provided with the application. This is important in the case that a Child Protection, health or behavioural issue arises. Edmund Rice Camps NSW will not accept referrals without an after hours contact number for the referring agency . A contact number for a family or friend is not an appropriate substitute for an agency after hours number.
5. It is the responsibility of the Agency to ensure that the participant has appropriate clothing and equipment for the camp. The ERC office must be notified in advance if extra clothing and/or equipment are needed.
6. Junk food, drinks and electronic devices (including mobile phones) are all prohibited on camp. This needs to be discussed with children before camp. Any children with these items on camp will have them confiscated, and returned to their carers at the end of camp.
7. Transport of the participant(s) to and from the designated pick up and drop off point, at the commencement and conclusion of the camp, is not the responsibility of Edmund Rice Camps.
8. Should a participant need to be sent home from a camp, due to illness or inappropriate behaviour, it is the responsibility of the Agency (and parent/guardians) to provide transport . It is important that should a situation arise that requires a child’s removal from camp, this is able to be managed in a quick and efficient manner. As such, we are unable to accept referrals for any child who lives or is case managed by an employee who is further than a 2 and a 1⁄2 hour drive from the campsite in Mulgoa, NSW.
9. It is the responsibility of the Agency to pay the participant fee before each program. Edmund Rice Camps NSW acknowledges that Agencies may seek a contribution of this fee from the participant’s family, however it remains the responsibility of the Agency to ensure that this fee is paid.
Important information about the Protection of Children:
1. Edmund Rice Camps NSW is a Child Safe Organisation. We have a zero tolerance of abuse. A Child Protection Matter is any information relating to a child under 18 years of age pertaining to any past or current, actual or suspected concern for a child's safety, welfare or health.
2. If a Child Protection Matter arises on a program, Edmund Rice Camps NSW will follow our safeguarding policy available here .
3. To lodge a professional standards complaint, contact Jennifer Lewis, Edmund Rice Community Services Safeguarding Coordinator on 0438 917 505 or JLewis@edmundrice.org
I, as the referring agency worker, have read and understood the above conditions under which Edmund Rice Camps NSW conduct programs in New South Wales. Based on this information, I believe the applicant I am referring for placement on this program is suited to the conditions under which the program is to operate. *

Yes No
Referral Agency Worker Name *

First Name Last Name
Referral Agency Worker Signature

Clear
Date Signed

Month Day Year

Privacy & Permissions (for Parents/Guardians/Carers)

Designated Guardian to complete
PHOTO RELEASE CONSENT

In order to provide a Child Safe environment, photographs on camp are only taken by one member of the Camp Executive Leadership team, or their delegate. Photographs are for Edmund Rice Camps NSW use only and not for general distribution. At times, photographs and/or video footage of your child may be used for the purposes of sharing the work of Edmund Rice Camps with the broader community, including possible funding partners. This may be for publicity, grant applications or on our website. We never include identifying information with images of any children.

Photographs will not be used without consent. Parents and Guardians should be aware that when information is published on public websites and social media channels, it can be discoverable for a number of years, if not permanently. Published information can also be linked by third parties.

You can view our Privacy Statement here.
I have read the above permission to publish and: *

I do give permission I do not give permission
PERMISSION TO ATTEND AND MEDICAL AUTHORITY

I, {parentguardiancarersName}, being parent / guardian of {fullName} give permission for them to engage and participate in this Edmund Rice Camp for the dates mentioned, as well as the designated Edmund Rice Camp Picnic Day. I acknowledge that the supervisors will take every care at the camp and have undergone special training in caring for children. I accept that the supervising adults (volunteers and staff) will not incur liability for any accidental injury sustained by my child.

I further authorise that Edmund Rice Camps Supervisors, in the event of any accident or illness and where it is not possible or reasonable to obtain my consent at the time, to engage any medical practitioner or hospital facilities and in this event I agree to pay all such ambulance, doctor, nurse or hospital expenses. I expect that I will be informed as soon as possible.

I have read and I accept the above conditions and disclaimer relating to participation in Edmund Rice Camps NSW programs and I give my permission for my child to take part in them.
Parent/Guardian/Carer Signature

Clear
Parent/Guardian/Carer Name
Date Signed

Month Day Year
DD/MM/YYYY

Submit

Please ensure all pages and fields are completed. Edmund Rice Camps NSW are not able to consider an application that is not complete. If you have any queries, please contact our friendly staff!
Should be Empty:

	Name of Medication	Required Dose	Frequency/ Time of Day	Other Comments
Medication 1
Medication 2
Medication 3
Medication 4
Medication 5

	Always	Some-times	Not often	Never	Not sure
Does this child engage well with others in group activities?
Does this child support and encourage their peers?
Does the child need support to engage positively with others?
Is this child sensitive to noise and/or busy environments?
Is the child likely to experience homesickness?
Does the child have a history of absconding (running away and/or hiding from adults)?
Does the child have a history of damaging or vandalising property?
Does this child struggle with transition times (e.g. arriving and leaving camp, going to bed)
Does the child have challenges responding to directions from positions of authority (e.g. parents/carers, teachers)?
Does the child exhibit any verbally aggressive behaviours including yelling at others, screaming, swearing, threatening others etc.?
Does the child exhibit any physically aggressive behaviours including physically intimidating others, pushing, kicking, cornering, punching, slapping etc.?
Does this child exhibit any self-harming behaviours?
Does this child exhibit any sexualised behaviours, including but not limited to sexualised talk, touching their genitalia in front of others, touching the genitalia of others, talking about touching their genitalia or others, engage in pornographic material etc.?
Do you have any reason to believe that this child may place themselves, staff, volunteers or other children at risk in any way?

	Current (present in the last month)	On-going (for 6 or more months)	Historical (1 or more years ago)	Not applicable/not sure
Physical Abuse
Emotional Abuse
Sexual Abuse
Physical Neglect
Emotional Neglect
Mental Illness in the home
Incarcerated Carer or Parent
Witnessing Domestic Violence
Substance Misuse in the Home
Divorce or parental separation
Exposure to, or involvement in criminal activity
Parentification (child taking on carer responsibilities of others in the home)
Death of a loved one
Bullying and/or social isolation
Prolonged absence of a parent/separation from a parent

ERCNSW Winter Tuross Head Camp

Participant Details

Medical Details

Non-prescription Medication Consent

COVID-19

Interests & Behavioural Profile

Family and Child's History

Conditions of Placement (for Referrers)

Privacy & Permissions (for Parents/Guardians/Carers)

Submit