Pwsa Vic Time Out Camp 2021 Carer Registration

PWSA VIC 2023 TIME OUT CAMP

Carer Registration Form
The Prader-Willi Syndrome Association of Victoria is pleased to invite you to our 9th Annual Time Out Camp

Where: Camp Toolangi 235 Spraggs Road, Toolangi Victoria www.camptoolangi.com.au (between Kinglake and Healesville)

When: Carers are required to arrive at Camp Toolangi at 9:00am March 11th for a debriefing session. The camp will run until March 13th 2023.

Getting there: The Camp is located 1 hr from Melbourne CBD. Transport to and from the Camp is the attendees’ responsibility

More information will be emailed out closer to the date to those who have registered including directions, what to bring, the Camp Program and the Camp Menu.

Please do not hesitate to email Kurstie Jenkins* at Kurstie.jenkins@pwsavic.org.au if you have any questions, suggestions or comments.

Looking forward to seeing you there!

ALL INFORMATION IS REQUIRED TO BE COMPLETED BY THE CARER ATTENDING THE CAMP

DETAILS OF THE CARER ATTENDING:
Full Name:*

First NameLast Name
Date of Birth:*

DayMonthYear
Gender:*

MaleFemaleI'd rather not say
Address:*

Street Address

Street Address Line 2

SuburbState

Post Code
Email:*
example@example.com
Phone Number:*
T-Shirt Size:*
Meal Size:*

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

PROFESSIONAL DETAILS/EXPERIENCE:
Current employer:*
Position:*
Do you have a working with children's check?*

NoYes
WWCC number:
WWCC Expiry date:*

DayMonthYear
Do you have a first aid certificate?*

NoYes
FAC number:
FAC Expiry date:*

DayMonthYear
List any other relevant qualifications:

DIETARY INFORMATION:
Do you have any FOOD ALLERGIES? (Enter food intolerences in Dietary requirements)
If an allergic reaction is triggered would this require emergency medical intervention or use of an EpiPen?
Do you have any special dietary requirements? Intolerence, cultural or lifestyle.
MEDICAL INFORMATION:
We are unable to record and store medical information. However, if you feel that you have a condition that should be shared please speak to Sarah Rees prior to or at the camp.Do you have any health issues that require discrete discussion?

YesNo
COVID - 19

You must not attend Camp Toolangi if you are demonstrating any symptoms of COVID-19 or are waiting on results of a COVID-19 test. If at any time you 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.
COVID-19 requirements*

I have read, understood and agree to comply with the above COVID-19 requirements.

DETAILS OF EMERGENCY CONTACT/S:

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

First NameLast Name
Phone Number:*
Relationship:*
Name of Emergency Contact 2:if available

First NameLast Name
Phone Number:
Relationship:

PRIVACY STATEMENT:

Please read
Please tick*

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

CHILD SAFETY POLICY:

Please read
Please tick*

I have read and will abide by the PWSA VIC Child Safety Policy
Please upload a copy of you Working with Children's check

Browse Files

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MEMBER PROTECTION DECLARATION:
The Prader-Willi Syndrome Association of Victoria (PWSA Vic) has a duty of care to its members and to the general public who interact with its employees, volunteers, members and otherS involved with PWSA VIC activities. As part of this duty of care and as a requirement of PWSA VIC’s Member Protection Policy, the PWSA VIC must enquire into the background of those applying for, undertaking or remaining in any work (paid or voluntary) that involves direct and unsupervised contact with people under the age of 18 years.
I declare that ....

1. I do not have any criminal charge pending before the courts.

2. I do not have any criminal conviction or findings of guilt for sexual offences, offences related to children or acts of violence.

3. I have not had any disciplinary proceedings brought against me by an employer, organisation or similar body involving child abuse, sexual misconduct or harassment, acts of violence, intimidation or other forms of harassment.

4. To my knowledge there is no other matter that PWSA VIC may consider to constitute a risk to its members, employees, volunteers, athletes or reputation by engaging me.

5. I will notify the Chairman of the organisation engaging me immediately upon becoming aware that any of the matters set out in clauses 1-4 above has changed for whatever reason.
Please tick*

I have read, understood and answer YES to all the above

TERMS AND CONDITIONS:
- I have completed this form truthfully and to the best of my knowledge.
- In the event of a medical emergency, all effort will be made to contact the emergency contact person listed on this form in first instance. If contact cannot be made, I authorise that medical attention be sought immediately and administered if required. Also, I consent to being transported in a privately owned vehicle driven by camp organisers (or their representative) or by ambulance to nearest hospital if required. I understand that any medical costs incurred are my own responsibility.
- I agree that the medical or dietary information contained in this registration form 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 that I will be asked to leave and the relevant authorities will be informed.
- I understand that personal property such as mobile phones, iPads, etc are permitted at the camp but that I take sole responsibility for that property. It will not be the responsibility of camp organisers to locate lost property or provide 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 me arising out of travelling to, participating in, or returning from the Time Out camp.
Please tick*

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

CONSENT TO BE PHOTOGRAPHED:
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 make their wishes known PRIOR to the event to the Event organiser (info@pwsavic.org.au) or alternatively the President of the PWSA Vic (Renee.digenova@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, 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 out closer to the date to those who have registered, including directions, what to bring, the Camp Program and the Camp Menu.

If you have any questions, comments or suggestions, please contact Kurstie Jenkins at info@pwsavic.org.au or write in the feedback space below.
Feedback
THANK YOU!
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PWSA VIC 2023 TIME OUT CAMP

DETAILS OF THE CARER ATTENDING:

PROFESSIONAL DETAILS/EXPERIENCE:

DIETARY INFORMATION:

MEDICAL INFORMATION:

COVID - 19

DETAILS OF EMERGENCY CONTACT/S:

PRIVACY STATEMENT:

CHILD SAFETY POLICY:

MEMBER PROTECTION DECLARATION:

TERMS AND CONDITIONS:

CONSENT TO BE PHOTOGRAPHED:

MORE INFORMATION: