Young Men's Bush Retreat Application

1
Participant's Full Name* This field is required.
First Name
Last Name
2
Participant's Date of Birth* This field is required.Participants must be at least 13 years of age
Date
Day
Month
Year
3
Parent or Guardian* This field is required.(Also Emergency Contact - if that will be different please inform us in notes later in this application)
First Name
Last Name
4
Parent or Guardian Email Address* This field is required.
example@example.com
Confirm Email
5
Parent or Guardian Best Contact (phone)* This field is required.
6
Best contact time?
7
Select from currently available dates:* This field is required.Starting late Friday, finishing late Sunday
January 1st - 4th - SOLD OUT
April 9th - 12th 2026
8
Please make a selection:* This field is required.If you are successful in securing a position, you will be contacted with payment information
I would like to pay the full amount of $748 via bank transfer
I would like to discuss pay-off options
9
For Parents or Guardians: Why would you like the young man to participate, and what would you like for him to get out of the experience?
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Ok
10
For Participants: What would you like to get out of your experience?
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11
Please list any essential and/or relevant information about the participant - ie, Neurodivergence, Dietary Requirements, Medical Conditions, Injuries. Reasonable fitness is required for safety.Neurodivergence does NOT automatically disqualify someone from a position
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12
Does the child require medication, and will this be self-administered? Please note that we DO NOT take responsibility for the administration of medication on the camp.Feel free to note if you would like to discuss this
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13
Optional: How did you hear about us?(From a friend, Facebook group, Facebook ad etc)
14
By clicking 'next', you acknowledge that you have read and agree to the Refund Policy and Terms Of Service.

Notes regarding refunds will be included in an email upon submission of this form. You are not required to make payment in order to submit this form.
15
That's it!

Thank you for taking the time to register. All you need to do now is click Submit, and you will be contacted in the coming days.

Thank you!
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