PWSA VIC 2021 Time Out Camp registration

2022 TIME OUT CAMP

Registration Form
We are very excited to be able to bring our community together in this unique supportive and fun environment.

The Time Out Camp is designed to encourage those living with Prader-Willi Syndrome and their families to develop life-long friendships, build resilience and self-confidence all while gaining an understanding of PWS in a supportive and fun environment.

Our main focus is to encourage inclusion for all, by providing a range of fun outdoor activities suited to all abilities and ages. And, our professionally facilitated educational sessions and programs are designed to arm families with information and skills to help them navigate their PWS journey and best care for and support themselves and their loved one with PWS.

So, no matter how young or old you are, there is something to be gained by all who attend the Time Out Camp.

CALCULATING THE FEES
Number of individuals with PWS:
Is the individual with PWS aged 0 to 2 years?

YesNo
Fee:
Number of Parents/Carers attending:*
(At least 1 parent or carer must accompany the person with PWS under 18)
Fee:
Number of others attending 12yo and over:*
Fee:
Number of other Children attending between 3yo and 11yo:*
Fee:
Number of other Children attending 2yo and under:*
(FREE)
TOTAL number of people attending:
TOTAL Fees:
Payment of the above agreed amount. Option to pay online at completion of this registration is available.

Yes, I will make full payment online today during the completion of this registration. I will indicate later if I require a receipt for NDIS purposes.I will not be making a payment today but I will make a payment to PWSA Vic upon receipt of payment invoice issued on completion of this online registration. Enter $0 in agreed payment field below NB: Payment is due within 7 days of online registration. Non-payment may result in your application being cancelled.I have discussed my payment with PWSA Vic . Enter the agreed amount below if making any payment at this time or enter $0
The Amount I have agreed to pay is:

DETAILS OF THE PERSON WITH PWS ATTENDING:
Full Name:*

First NameLast Name
Address:*

Street Address

Street Address Line 2

SuburbState

Post Code
Date of Birth*

DayMonthYear
Phone Number: (if applicable)
T-Shirt Size:*
Child and Adult sizes available
Meal Size: These meals are nutrient dense, and therefore large with reduced Calories*

Small (approx. 700 Calories)Medium (approx. 1200 Calories) Average adult serveLarge (approx. 1800 Calories) 1.5 x Average adult serveNone - I will byo baby food (option for 2yo and under)

DETAILS OF OTHER ATTENDEES:

Parents/Carers
Name of Parent/Carer 1:*

First NameLast Name
Parent/Carer 1. Phone Number:*
Parent/Carer 1. T-Shirt Size:*
Parent/Carer 1 - Meal Size: These meals are nutrient dense, and therefore large with reduced Calories*

Small (approx. 700 Calories)Medium (approx. 1200 Calories) Average adult serveLarge (approx. 1800 Calories) 1.5 x Average adult serve
Name of Parent/Carer 2:*

First NameLast Name
Parent/Carer 2 Phone Number:
Parent/Carer 2. T-Shirt Size:*
Parent/Carer 2 - Meal Size: These meals are nutrient dense, and therefore large with reduced Calories*

Small (approx. 700 Calories)Medium (approx. 1200 Calories) Average adult serveLarge (approx. 1800 Calories) 1.5 x Average adult serve

DETAILS OF OTHER ATTENDEES:

CHILD(REN) AGED 2YO AND UNDER
Name of other Child (2yo and under) 1:*

First NameLast Name
How old is this child?*
T-Shirt Size:*
Meal Size:*

Small (approx. 700 Calories)None - I will byo baby food
Name of other Child (2yo and under) 2:*

First NameLast Name
How old is this child?*
T-Shirt Size:*
Meal Size:*

Small (approx. 700 Calories)None - I will byo baby food

DIETARY INFORMATION:
Does anyone listed on this form have any FOOD ALLERGIES? (Enter food intolerences in Dietary requirements)
Note: If more than one person on registration please list name of person/s with these requirements.
If an allergic reaction is triggered would this require emergency medical intervention or use of an EpiPen? Are you or an attending family member able to administer the EpiPen?
Does anyone listed on this form have any special dietary requirements? Intolerence, cultural or lifestyle.
Note: If more than one person on registration please list name of person/s with these requirements.
MEDICAL INFORMATION:
Does anyone listed on this form have any medical conditions that the accompanying carer should be aware of? Answer only yes or no below.
Please Note: PWSA Vic is unable to retain medical records.; If for any reason the primary carer of the individual who may require treatment leaves the camp grounds they must inform the camp organisers of any possible requirements..

DETAILS OF EMERGENCY CONTACT/S:

(NOT ATTENDING THIS CAMP)
Name of Emergency Contact 1:*

First NameLast Name
Phone Number:*
Relationship to the person with PWS:*
Name of Emergency Contact 2: if available

First NameLast Name
Phone Number:
Relationship to the person with PWS:
COVID - 19

You must not attend Camp Toolangi if you or any people on this registration form are demonstrating any symptoms of COVID-19 or are waiting on results of a COVID-19 test. If at any time any of the listed people start to experience symptoms you must notify Camp Toolangi staff and PWSAV camp organisers and immediately self isolate. You must abide by the requirements set by Camp Toolangi in regards to check-ins, mask wearing,hand sanitising and general cleaning where applicable and mandated by the Vic government at the time.
I have read, understood and agree to comply with the above COVID-19 requirements.*

Yes

PRIVACY STATEMENT:

To be agreed to by the person responsible for all those listed on this form
Please tick*

I have read and understood the above statement and agree to the terms as outlined

TERMS AND CONDITIONS:

To be agreed to by the person responsible for all those listed on this form
- I give my consent for all those listed on this form to participate in the PWS Time Out Camp 2022 and all activities organised by PWSA Victoria during the camp at Camp Toolangi.
- I know that if any participant is unwell or suffers any injury, I must report it to the carer and/or camp organisers. The provision of First Aid will be available at the camp and administered by suitably qualified staff.
- In the event of a medical emergency, all efforts will be made to contact the parent or carer listed, emergency contacts on this form in the first instance. If contact cannot be made, I authorise medical attention to be sought immediately and administered if required. Also, I consent to the individual being transported in a privately owned vehicle driven by camp organisers (or their representative) or by ambulance to the closest hospital if required. Ambulance and any other medical expenses are the responsibility of the individual, family member or representative completing this registration.
- I agree that any medical information contained in this registration form or given to camp or PWSA Vic representatives may be made available to appropriate people rendering assistance or from whom advice may be appropriate.
- I understand that in the event of inappropriate behaviour or behaviour that poses a danger to others during the camp, the participant/s will be asked to leave. I further understand that in such circumstances, any costs associated with his/her/their return will be my responsibility.
- I understand that personal property such as mobile phones, iPads, etc. are permitted at the camp, but I take sole responsibility for that property. Camp organisers will not be responsible for locating lost property or providing reimbursement.
- I acknowledge and consent to the risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless PWSA Victoria and all its respective officers, agents, and representatives from any and all liability for injuries to the participant/s arising out of travelling to, participating in, or returning from the Time Out camp.
Please tick*

I have read and understood the above statement and agree to the terms as outlined

CONSENT TO PHOTOGRAPHY/VIDEOGRAPHY:

To be agreed to by the person responsible for all those listed on this form
The Prader-Willi Syndrome Association of Victoria (PWSA Vic) reserves the right to use any photograph/video taken at any event hosted by PWSA Vic, without the expressed written permission of those included within the photograph/video. PWSA Vic may use the photograph/video in publications or other media material produced, used or contracted by PWSA Vic including but not limited to: brochures, invitations, booklets, newspaper articles, social media publications, email notifications, websites, etc.

To ensure the privacy of individuals and children, images will not be identified using full names or personal identifying information without written approval from the photographed subject, parent or legal guardian

However, a person attending a PWSA Vic event who does not wish to have their image recorded for distribution should, prior to the event, make their wishes known to the event organiser or the President of the PWSA Vic at info@pwsavic.org.au in writing of his/her request and include a photograph. PWSA Vic will use the photo for identification purposes and will hold it in confidence.

By participating in a PWSA Vic event or by failing to notify PWSA Vic, in writing, your desire to not have your photograph used by PWSA Vic, prior to the event you are agreeing to release, defend, hold harmless and indemnify PWSA Vic from any and all claims involving the use of your picture or likeness.

Any person or organization not affiliated with PWSA Vic may not use, copy, alter or modify PWSA Vic photographs, graphics, videography or other, similar reproductions or recordings without the advance written permission of an authorised designee from PWSA Vic.

Thank you for your understanding and cooperation.
Please tick*

I have read and understood the above disclaimer and agree to the terms as outlined
Signature*

Clear
Use your mouse or finger to sign

MORE INFORMATION:
More information will be emailed to the applicant closer to the camp date. Details will include directions, what to bring with you, the Full Camp Program, and details of the Camp Menu.

If you have any questions, comments or suggestion please contact Sarah Rees on sarah.rees@pwsavic.org.au or on ph: 0408 304 279 or write in the feedback space below.
Feedback

PAYMENT:
Fee
Donation:
Donations of $2 or more are tax deductable
Total
Secure online payment.

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Do you require an official receipt to submit a claim to NDIS ?

Yes please send me an official receipt for NDIS.
Main Contact Person:*

First NameLast Name
Please send all emails relating to this camp to:*
Should be Empty:

2022 TIME OUT CAMP

CALCULATING THE FEES

DETAILS OF THE PERSON WITH PWS ATTENDING:

DETAILS OF OTHER ATTENDEES:

DETAILS OF OTHER ATTENDEES:

DETAILS OF OTHER ATTENDEES:

DETAILS OF OTHER ATTENDEES:

DIETARY INFORMATION:

MEDICAL INFORMATION:

DETAILS OF EMERGENCY CONTACT/S:

COVID - 19

PRIVACY STATEMENT:

TERMS AND CONDITIONS:

CONSENT TO PHOTOGRAPHY/VIDEOGRAPHY:

MORE INFORMATION:

PAYMENT: