Breakaway Application Form

Child/Participants details:

Name*

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth

Date

Camp Wanting Sponsorship For

Campground camp is held at*

Pindari Adventures/LifeOther

Parent/Guardians Details:

Name*

First NameLast Name

Phone Number

Please enter a valid phone number.

Email*

example@example.com

Relationship to Child/Participant

Sponsorship definitions:

Half sponsorship - We get it, camp can be expensive for everyone and maybe you just can't afford the full fees. This is why we've come up with the idea where you pay half, we pay half, and everyone wins.

Full sponsorship minus deposit - This is the preferred method. You pay the deposit when you register and we cover the rest of the rego fee.

In most cases the deposit should be affordable, however we understand that this cost can sometimes be unaffordable which is why we also offer the following two options:

Full Interest Free Repayment Plan - We cover the deposit, we cover the rego fee, and when you have the money you can pay us back. There is no interest, there is no time limit; you just pay us back when you can afford it.

Full sponsorship - We cover the deposit, we cover the rego fee, and we expect nothing in return.

Please select which sponsorship you're applying for*

Half SponsorshipFull Sponsorship minus depositFull Interest Free Repayment PlanFull Sponsorship

Eligibility Definitions

To see if you can apply for socio economic disadvantaged funding please check if your address registers in the 1-2 quintile areas on the following map:

https://experience.arcgis.com/experience/32dcbb18c1d24f4aa89caf680413c741/page/IRSD/

Which eligibility category are you applying for?*

We have a Low Income Health Care cardWe live in a Socio-Economic Disadvantaged areaWe are affected by a natural disasterOther

Health Care Card number

Please list natural disaster and how it's affected you

For example: drought, loss of livestock - or bushfire, loss of buildings - or drought, loss of income