Child Referral Form- Program

Agency and Billing Information
Please give your details as the referrer. An invoice for payment of camp fees, if applicable, will be addressed to your agency and sent to your email address. Payment of this invoice is non- refundable and will secure this child's place on camp. Failure to make payment by the due date with forfeit the participant's place to another participant on our waiting list.
Name of Agency*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Representative*
Type of Support provided to child/ family*
How long have you provided this support?*
We require two phone numbers from the Agency making a referral.
One is the key contact person, making the referral who would call for general information in the lead- up and post the program.
The other is for a 24- hour contact person or on call number that we would use only in emergency (if we could not get on to a family member) and to provide support and context if we have a child protection concern.
If you are not from an organisation partner, we will invoice the organisation with attention to the agency representative with the following fees:
- Head2Heart overnight program $60.00 per child
Agency Representative Phone Number*

Area CodePhone Number
24 hour Contact- Used for Emergency only*

Area CodePhone Number
Agency Representative Email*
example@example.com
Name and contact detail for payment invoice

Parent/Guardian Details
Parent/Guardian Name*

First NameLast Name
Relationship to child?*
Phone Number*

Area CodePhone Number
Email*
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Details

If parent/guardian cannot be reached.
Contact Name*

First NameLast Name
Relationship to child?*
Phone Number*

Area CodePhone Number

Terms and Conditions
Please read the following information relating to camps conducted by Edmund Rice Camps Queensland (ERCQLD). A signed copy, signifying acceptance of these conditions and a belief on the Agency’s part that the participant(s) seeking placement is suited to ERCQLD programs, must accompany each application for placement on an Edmund Rice Camp.

1. ERCQLD are staffed entirely by volunteers, principally aged 17 to 30. While volunteers with some professional qualifications hold executive leadership roles on each camp, the majority of leaders do not hold such qualifications.

2. All information that may affect the behaviour of the participant(s) on the camp, including their interaction with leaders and other participants within the age range of the camp, must be forwarded with the application and be correct and accurate.

3. 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 ERCQLD.

4. 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 that child's safety, welfare or health.
4a. If a Child Protection Matter arises on camp, ERCQLD will make contact with the Agency to provide details of the matter. ERCQLD in collaboration with the Agency will then develop a plan to notify and support the child and family, and to contact the Department of Child Safety where appropriate. The Agency will notify ERCQLD prior to the release of this information to the family or carer if done so while the child is attending an ERCQLD program.
4b. The Agency will notify ERCQLD of any relevant and ongoing Child Protection Matter about the child prior to the beginning of the camp. This information will be kept in confidence.
4c. The Agency’s 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.

5. Should a participant(s) need to be sent home from a camp, due to illness or inappropriate behaviour, it is the responsibility of the Agency to provide transport.

6. ERCQLD reserves the right to accept or reject any application based on the best possible match between applicants and the skills of the volunteers on a particular camp.

7. It is the responsibility of the Agency to ensure that the participant has appropriate clothing and equipment for the camp. If extra clothing and/or equipment are needed, please contact the ERCQLD office prior to the commencement of the program to discuss and access alternatives.

8. The participant(s) may be invited to take part in an optional evaluation of the camp, all responses will be confidential, the responses will be collated along with responses from agencies and volunteers then de-identified to evaluate the entire camp and its processes. ERCQLD values all feedback received. The purpose of the evaluation is to expand on the resources and programs delivered by ERCQLD in future.

9. It is the responsibility of the Agency to pay the participant fee before camp under the guidelines of the invoice. ERCQLD 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 and on time. Failure to make timely payment of the fee will result in the withdrawal of the placement offer.

10. Prior to camp ERC incurs costs including catering, accommodation and equipment. ERC is therefore unable to refund the participant fee in the event that the participant can no longer attend the program. As a not-for-profit, ERC subsidises the fees through fundraising, in-kind donations and significant volunteer support.

Consent and Disclaimer
IMPORTANT: THE SECTION BELOW MUST BE SIGNED PRIOR TO CAMP, JOINTLY BY REFERRING AGENT AND PARENT/CARGIVER

Subject to any law to the contrary, and to the maximum extent permitted by law, Edmund Rice Services Ltd (trading as Edmund Rice Camps) and its officers, employees and agents disclaim all liability for any loss or damage (whether foreseeable or not) suffered by any person participating on a camp offered by Edmund Rice Services Ltd whether the loss or damage arises in connection with any negligence, default or lack of care on the part of Edmund Rice Services Ltd or any of its representatives or any other cause.

I, as parent/guardian of this child, authorise designated personnel of Edmund Rice Camps to administer prescribed medications, as supplied by me, in the dosages outlined herein. I authorise the administration of over-the-counter medications as outlined herein.

I authorise the designated representatives of Edmund Rice Camps to administer medical treatment as needed.

In the event of any accident or illness (and where it is not possible or reasonable at the time to obtain my consent), I authorise Edmund Rice Camps personnel to engage medical assistance or treatment, including (but not limited to) ambulance, general practitioner, or hospital. For this purpose, I agree to pay all such medical expenses incurred.

Photographs and/or video footage may be taken of your child to be used by Edmund Rice Camps for our own promotional purposes. We never include identifying information with images of children.
Images Consent*

I DO NOT give permission for images of my child to be usedI GIVE permission for images of my child to be used by INTERNALLY ERCQLD. This means the images will only be used for promotion within the Edmund Rice Camps community through modes such as emails and internal letters.I GIVE permission for images of my child to be used EXTERNALLY by ERCQLD. This means that images may be used on our official website and associated official social media profiles, meaning they are visible to the general public.
I have read and I accept the above conditions and disclaimer relating to participation in Edmund Rice Camps Queensland programs and I give permission for my child to take part in them.
It is difficult to meet the family in person, I have gained verbal consent and will initial on their behalf.

Yes, initialling below on their behalf
Parent/Guardian Signature*

Clear
Parent/Guardian Full Name:*
Relationship to Child*
Date Signed*

MonthDayYear
Date
I have read and understood the above conditions under which Edmund Rice Camps Queensland conduct programs. Based on this information, I blieve teh child I am referring for placement on this camp is suited to the conditions under which the camp is to operate.
Referring Agency Contact Signature*

Clear
Referring Agency Contact Name*
Date Signed*

MonthDayYear
Date
EDMUND RICE CAMPS QUEENSLAND

Email: ercsqldspl@edmundrice.org
Website: www.ercampsqld.org
Facebook: www.facebook.com/ercqueensland
Instagram: @ercqld
Should be Empty:

	Medication Name	Taken with Food?	Dosage (ml/mg)	How Much (1 x tablet?)	As Required?	Before Breakfast	Breakfast	Lunch	Dinner	Bedtime	Other
Medication 1
Medication 2
Medication 3
Medication 4
Medication 5

Child Referral Form

Child Information

Transport Information

Agency and Billing Information

To be completed by the Referring Agency

Parent/Guardian Details

Emergency Contact Details

Medical Information

Terms and Conditions

Consent and Disclaimer