CHILD PARTICIPANT - SAFARI 2023 REGISTRATION

CHILD PARTICIPANT - SAFARI 2023 REGISTRATION FORM

In line with our commitment to safe ministry practices, the information collected in this form will be used by appointed program leaders and stored securely by Southern Cross Presbyterian Church. PLEASE COMPLETE ONE FORM PER CHILD.
LETTER TO PARENTS/GUARDIANS OF CHILD PARTICIPANTS
Dear Parent/Guardian

We refer to the Safari youth camp on July 8-12, 2023 which Southern Cross Presbyterian Church is conducting.

We understand that your child wishes to attend this activity. There are certain risks inherent in this activity and it is important that we draw these to your attention before your child participates in the activity. It is a requirement of the Church and its insurer that before your child undertakes this activity, you complete the form below.

Please complete the form below by Sunday, June 4.
Please note that we will observe strictly the requirement, no form, no attendance.

Please note that the obligation to take out insurance to cover personal injury to your child/travel insurance rests with you.

Yours sincerely,

Cameron Bryant
Youth Coordinator
I have read an understood the 'Letter to Parents/Guardians of Child Participants'.*

Yes, I have read an understood the 'Letter to Parents/Guardians of Child Participants'.
PARTICIPANT INFORMATION
Child's Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Year at school*

Year 7Year 8Year 9Year 10Year 11Year 12
Gender

MaleFemale
Shirt size (note adult sizing)*

XSSMLXLXXL
Does your child have any dietary requirements?*

Yes (if 'yes' please outline below)No
Please outline specific dietary requirements for your child here:
PARENT/GUARDIAN CONTACT INFORMATION

Please provide the information of the Parent/Guardian completing this form.
Parent/Guardian Name*
Full Name
Relationship to Child*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
MEDICAL INFORMATION & MEDICAL AUTHORITY CONSENT
My child has a medical condition, allergy, asthma, anxiety and/or dietary requirements.*

Yes (if 'yes' please outline below)No
Please provide specific details about condition, allergy, asthma, anxiety etc.(including severity, regular medications and treatment/management). *
My child requires medication to be administered by program leaders during Safari (if you select 'yes' please note that a separate form will be required and a program leader will be in contact regarding this).*

YesNo
Medicare Number (include child's position on card in brackets at end)*
Medical fund
As the parent/guardian of the child participant I understand and acknowledge the following:*

I acknowledge the above event (Safari 2023) entails certain risks inherent in this type of activity. I also acknowledge the Organisation and its helpers will make every reasonable effort to ensure the safety of the participant which may attract injury or loss.I authorise the Organisation to arrange immediate medical attention or treatment, including surgery and/or administration of anaesthetics as the case may require, or is likely to require. Such treatment will be authorised in writing or otherwise.I accept responsibility for payment of any expenses incurred, including transportation.I also acknowledge the Risk Warning constitutes a risk warning pursuant to the Civil Liability Act 2002 (including any amendments).I acknowledge and accept that there is a risk that my child may be exposed to COVID-19 whilst attending and participating in Safari 2023. I confirm that my child will not attend if displaying any symptoms of illness.I understand that should my child develop flu-like symptoms a rapid antigen test (RAT) will be used (parent/carer will be contacted by a leader via phone to seek permission before administering the test).I acknowledge that should my child test positive whilst at Safari 2023, OR does not have permission to undertake a RAT, they will be required to isolate and be collected by a parent/carer.
EMERGENCY CONTACT INFORMATION
Emergency contact (other than parent/guardian listed above)*

First NameLast Name
Relationship to child*
Phone Number*
Please enter a valid phone number.
RISK WARNING
In planning Safari 2023, the program leaders have considered the following safety/risk factors including, but not limited to - transport, terrain, sun/wind/insect protection, availability of toilets/drinking water, first aid kit, mobile phone coverage, hazard/risk/permission note with medical info for each participant, management of activities, volunteer adults having BTS Safe Ministry training & WWCC, sleeping arrangements, supervision ratios, fire safety, COVID/illness protocol, food hygeine/safety etc.
I am aware in signing this document for my child's participation in Safari 2023 ('the Activity'), that certain elements of the Activity may be physically and/or emotionally demanding. I acknowledge that in providing me with this document, the Organisation has warned me that certain inherent physical and/or emotional risks and dangers may exist in the Activity. I acknowledge that while the Organisation and its staff/leaders will make every reasonable effort to minimise exposure to known risks, all hazards and dangers associated with these activities (including but not limited to the risks identified in the Schedule above) cannot be foreseen or may be beyond the control of the Organisation and staff/leaders. I agree that I understand the general nature of these risks may include physical injury and/or bodily injury including injuries that may be fatal; psychological injury, stress and or emotional distress; and associated trauma; howsoever caused.*

I understand.
By signing at the end of this form I, the parent/guardian of the child participant in this form:*

Agree to abide by any safety guidelines and/or written and/or verbal instructions in relation to the Activity as established by the Staff of the Organisation in charge for the duration of the Activity.Acknowledge that failure to abide by these guidelines could compromise safety and well-being, other participants and staff and my child would then be directed to leave the Activity.Acknowledge that the warning contained in this document constitutes a risk warning pursuant to the Civil Liability Act 2002.
IMAGE CONSENT
At Southern Cross Presbyterian Church (SCPC), we use photos and videos taken at our various activities and events to promote and celebrate our ministries. ‘Images’ (photographs and/or video recordings) may be used both internally and externally for publications and materials including (but not limited to) church family news, advertising materials, church family publications, church website and other online platforms. All images will be stored securely and used only as stated. Please note that names will never be included with images.*

I understand.
I give permission for images containing my child to be used both internally and externally for SCPC publications and materials including (but not limited to) church family news, advertising materials, church family publications, church website and other online platforms.*

Yes, I give permission.No, I do not give permission.
SIGNATURE
Name of parent/guardian completing this form.*

First NameLast Name
Please select from the following:*

I would like to sign on the screen below.I would like to upload my signature.
Please sign on the screen here:*
Please upload signature here:*

Cancelof
Date*

DayMonthYear
Date
PAYMENT
Below are the payment options for Safari 2023.

If you are able to pay in full, please select the first option.

The second option is available for those who may require an alternative payment option (i.e. a payment plan), or a subsidy in order for their child/children to attend. By selecting this option, Cameron will be in contact with you soon to make arrangements.
SAFARI 2023*
prevnext( X )
Safari 2023 Registration
$280.00AUD

Safari 2023 Registration (without payment)This small booking fee will be refunded.
$0.50AUD

Total

$0.00AUD

Payment Methods

Debit or Credit Card

First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Please click one of the PayPal options to complete payment and submit the form.

Should be Empty:

CHILD PARTICIPANT - SAFARI 2023 REGISTRATION FORM

LETTER TO PARENTS/GUARDIANS OF CHILD PARTICIPANTS

PARTICIPANT INFORMATION

PARENT/GUARDIAN CONTACT INFORMATION

MEDICAL INFORMATION & MEDICAL AUTHORITY CONSENT

EMERGENCY CONTACT INFORMATION

RISK WARNING

IMAGE CONSENT

SIGNATURE

PAYMENT