Camper Information Form

Gr. 7 Cameron Highlands / Gopeng, Malaysia: March 19 - 24, 2017Gr. 8 Bali, Indonesia: March 19 - 24, 2017Gr. 9 : March 19 - 24, 2017

Tioman Island, Malaysia

Name of College or School*

Class or Tutor Group*

Last Name (as appears in passport)*

First Name (as appears in passport)*

Date of Birth*

YearMonthDay

MaleFemale

Nationality*

Passport Number*

Passport Expiry Date*

YearMonthDay

YesNo

FoodinsectsMedicationFood Sensitivity/Intolerance

Details

Yes

YesNo

Supplementary information you wish to provide:

Details

B. To help us support your child, please advise us of any health or social/behavioural issues (other than those listed above) that could affect your child’s experience at camp (i.e. recent surgery or chronic or recent health conditions, fears or phobias, social or behavioural issues, limited mobility, etc.):

ABABO

PositiveNegative

YesNo

Date of last tetanus vaccination:

YearMonthDay

Details

VegetarianNon-Vegetarian

Please give a detailed description of what your child can, and cannot eat:

Details:

Name:*

MaleFemale

Address:

Street & Number*

City*

Province/State*

Country*

Home Phone*

Cell Phone

Work Phone

E-mail*

Name

MaleFemale

Same as First Parent

Street & Number

City

Province/state

Country

Home phone

Cell phone

Work phone

E-mail

Name*

Relationship*

Day phone*

Same as aboveOther

Cheque or Money orderElectronic Transfer – Please reference Trip and Student NameN/A - Payment has been made directly to School

Bank Name & Cheque No.

Name of Bene Bank: The Hongkong and Shanghai Banking Corporation Limited

Bene Bank Country: Singapore

Bene Bank Address: 21 Collyer Quay #01-01 HSBC Building Singapore 049230

Bene Name: Little Planet Sdn. Bhd.

Bene Account: (047)-391495-001

Brach Code: 047

Bank Code: 7232

Code: HSBCSGSG

1. Although travel insurance is included in Little Planet program fees, these policies are issued to the individual participant; should my child require medical services or medication during the course of the program, chargesfor such services and transportation will ultimately be the responsibility of the parent.

2. I will inform camp immediately if my child has been exposed to any contagious illness prior to camp.

3. I agree to allow Little Planet’s medical staff to dispense over the counter medication to my child for common ailments like headaches, ear aches, fever, etc. I will not hold Little Planet or the administrator of this/these medications in any way responsible for any reactions which my child may have to this medications if administered as directed.

4. In case of an emergency and having first attempted to reach the parents, I understand that Little Planet will seek a physician or dentist to treat my child during his/her stay at camp, as needed.

5. You must also read and agree to our liability waiver that you can read and download here: http://ourlittleplanet.org/downloads-for-schools/

I Agree to the aforementioned points and have read the Little Planet liability waiver

Parent Name*

First NameLast Name

Date:*

YearMonthDayHourMinutesAM/PM Option

CAMPER INFORMATION FORM

CHOOSE ONE OF THE PROGRAMS YOU WOULD LIKE TO ATTEND

NPS Intl. Singapore - Outdoor Adventure Education Programs

Renaissance College, Hong Kong

CAMPER INFORMATION

I. ALLERGIES & ASTHMA

II. HEALTH & SUPPORT

III. VACCINATIONS

IV. MEDICATIONS

V. DIETARY RESTRICTIONS AND SPECIAL INSTRUCTIONS:

VI. SWIMMING ABILITY

VII. CONTACT INFO.

A. FIRST PARENT INFORMATION

B. SECOND PARENT INFORMATION

EMERGENCY CONTACT (OTHER THAN PARENT)

VIII. PAYMENT METHOD

Account Information:

IX. CONSENT