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

Camp location is

Other

Parent/Guardians Details:

Name

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Relationship to Child/Participant

Which eligibility category are you applying for?

Other

Eligibility Definitions

If you are on a low income benefit please choose option 1 above and provide your HCC number.

To use option 2, please check your region for socio economic disadvantaged funding availability. Check if your address registers in the 1-2 quintile areas on the following map:

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

If your family has been disaster affected, please use option 3.

For any other disadvantage, please feel free to use "other" option in confidence - no further details required on this form; our coordinator will reach out to confirm your needs.

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

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 has a great time!

Deposit only options:

Interest Free Repayment Plan - You pay the deposit (varies per event, usually $50) when you register and we cover the remaining rego fee. 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 minus deposit - You pay the deposit (varies per event, usually $50) when you register and we cover the rest of the rego fee.

Please select which sponsorship you're applying for