Highland Home Kids Camp Leaders Registration Form

Camp Dates - please select which camp you are wanting to serve at*

Kids Camp - 4pm, Sunday 28th of September to 2pm, Friday 3rd October 2025

Name*

First NameLast Name

Birth Date*

MonthDayYear

Age*

Gender*

MaleFemale

Address*

Street Address

Street Address Line 2

City

Postal / Zip CodeCountry

Email*

Cell Phone Number*

Area CodePhone Number

Have you been a leader at another camp?*

YesNo

Which Camp?

Applying as a:

Leader in Training (LIT)Junior/Senior Leader

Payment Information - Please pay your fees in to:

Highland Home Christian Camp

01-0754-0006660-04

PARTICULAR: L/F-SEPT25

REFERENCE: Please use your child's initial & surname eg - J.Smith

Fees: Jnr/Snr $60

Leader In Training (LIT) $120

If you are registering a leader through a Governement organisation, please note that there will be a $20 administration fee added to their rate.

Discounts may apply to families with multiple children attending - please see your confirmation email for this rate.

Senior leaders may receive a subsidy on their fees, so please see your confirmation email for this rate.

Parent/Guardian Information - if under 18 years

Name*

First NameLast Name

E-mail

example@example.com

Emergency Information

Please note that these emergency contacts should be different to the above parent/guardian information.

1st Emergency Contact's Name*

First NameLast Name

Relationship*

Phone Number*

Area CodePhone Number

Alt. Phone Number*

Area CodePhone Number

2nd Emergency Contact's Name*

First NameLast Name

Relationship

Phone Number*

Area CodePhone Number

Alt. Phone Number*

Area CodePhone Number

Doctors Name*

Doctors Phone Number*

Transport Information: Who will drop you off and pick you up from camp?

Other Information: Please give us any information to assist camp staff.

Do you have any dietary requirements, allergies, chronic illness, or medical conditions that require treatment while at camp? If yes, please describe.*

Informed Consent and Acknowledgement

I declare that the details on this form are true and correct. I have read, understand and accept the Kids Camp Terms & Conditions: https://www.highlandhome.co.nz/wp-content/uploads/2021/03/Kids-Camp-Ts-Cs.pdf.

I hereby give my approval for my child’s participation in any and all activities prepared by Highland Home, on and off site, during Kids Camp.

I agree they will abide by camp rules and that I will pay for any willful damage caused by my child.

I authorise Highland Home to send my child information about future camps and for any photos or videos taken during camp to be used for publicity purposes if required.

I authorise Highland Home to present information regarding my child's registration and involvement of Kids Camp to governing agencies such as MSD and Oranga Tamariki for auditing purposes.

Making a Formal Complaint - I understand that I can make a formal complaint by downloading the 'Complaint Form' from: https://highlandhome.co.nz/wp-content/uploads/2019/10/Complaint-Form.pdf and following the instructions on the form.

Privacy Statement - I understand this information will not be shared with other persons or agencies without the consent of the parent/cargiver, except where there is a concern about safety and welfare of a child and as advised by the Police, MSD or Oranga Tamariki.

In case of injury to my child, I hereby waive all claims against Highland Home Christian Camp including all leaders and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners, trusees and managers and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all adventure activities. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.

Required*

Yes, I accept the informed consent and acknowledgement information

Medical Release and Authorization

While all care is taken in the administration of medication to campers, neither Highand Home trustees, management, staff or any other persons associated with the camp will be held responsbile for any error, adverse effect or other problems associated with or caused by the administration of any medication given to your child.

In case of a medical emergency I give Highland Home permission to seek medical help as required after first trying to contact me using the phone numbers given above. As Parent and/or Guardian of the named camper, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to Highland Home . and its affiliates including Trustees, Managers and Programme Leaders to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the camp.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

Required*

Yes, I accept the medical release and authorization information

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Electronic signature of acceptance - Full Name*

Home Number

Area CodePhone Number

Cell Number

Area CodePhone Number