2025 Camp Wambiri Application Form

Camp Wambiri Application Form

2024/25 Wambiri Youth Leadership Camp
Participant Category*
Participant Name*

First NameLast Name
Which Club are you a member of?*
Date of Birth*

MonthDayYear
Gender
T-Shirt Size*
Are you a patrolling member with any of the following qualifications that we could utilise in the program?

Bronze MedallionIRB DriverIRB CrewpersonRWC OperatorUAV Operator / PilotTrainer, Assessor or FacilitatorSurf Boat SweepNot a Patrolling MemberOther
Please provide your Working with Children Check number
If you do not have one, apply via https://ocg.nsw.gov.au/working-children-check
WWCC Expiry Date
Contact Details
Home Address*

Street Address

Street Address Line 2

City / TownState

Post Code
Contact Phone Number*
Contact Email*
example@example.com

Special Requirements
Please identify any dietary requirements (eg vegetarian, food allergies etc)
Please identify any special needs or requirements (eg wheelchair access)
Do you suffer from any medical conditions? (eg allergies, epilepsy, asthma, diabetes etc) Do you require medication for this condition? If yes to either question – please give details (attach sheet if required)
Upload medical details if required

Cancelof
Medicare Number
Please include position on card

Emergency Contact Details
Name*

First NameLast Name
Relationship
Mobile Phone Number*
Please enter a valid phone number.

Risk Waiver
In the case of an emergency, I authorise the program supervisors where it is impractical to communicate with me, to arrange for me to receive such medical or surgical treatment as may be deemed necessary.

I understand that although Surf Life Saving NSW, Surf Life Saving Far South Coast Inc and its service providers attempt to minimize risk of personal injury within practical boundaries, accidents do happen, and all physical activities carry the risk of
personal injury. I acknowledge and accept that there is an inherent risk of
personal injury in physical activities that will be undertaken as part of the
program.

I Agree*
Participant's Signature*

Clear
Guardian's Signature*

Clear

Media Consent
I * to allow Surf Life Saving Far South Coast Inc to use the participant's name and any photographs, sound and film recordings taken of the participant at this program for the promotion of the organisations services and initiatives to the media and the general public?
Participant's Signature*

Clear
Guardian's Signature*

Clear

Code of Conduct
The Code of Conduct outlines the standard of conduct expected of all members. As a participant at this program, you agree to meet the following requirements in regard to your conduct during the program (including both formal and informal activities).

1. Respect the rights, dignity and worth of others

2. Be fair, considerate and honest in all dealings with others, and be a positive role model

3. Make a commitment to providing quality service

4. Be aware of, and maintain an uncompromising adhesion to, SLSA standards, rules, regulations and policies

5. Demonstrate a high degree of individual responsibility, especially when dealing with persons under 18 years of age

6. Contribute to the provision of a safe environment for the conduct of all activities within surf lifesaving

7. Ensure that your actions are of the highest standard at all times, and that, at no time, will your conduct be construed as bringing SLSA or SLSNSW into disrepute

Further, you agree to:

a. abide by the code of conduct outlined above

b. maintain a ‘duty of care’ towards others and an accountability for matters relating to the program

c. foster a collaborative approach to the program and its activities

d. accept responsibility for your personal learning and that of the group

e. be a positive role model for surf lifesavers and SLSA.
Participant's Signature*

Clear
Guardian's Signature*

Clear
Should be Empty: