Cops N Kids Camp - Member Application Form

Camper Information

Your child's name*

First Last

Date of birth*

Gender*

Your child's t-shirt size*

Has your child ever slept away from home?*

Yes
No

Has your child ever attended a camp before?*

Yes
No

Has your child had contact with any contagious diseases within the last six weeks?*

For example: Chicken Pox, Measles, etc.

Yes
No

Please list and describe the contagious diseases:*

Are there any other concerns regarding your child attending this camp we should know about?*

For example: sleeping habits, etc.

Yes
No

Please list and describe any other concerns:*

Medical Information

A nurse will be on full-time duty during the camp. All information is confidential and solely for the guidance of the nurse/leader.

Does your child have any physical impairments or limitations?*

For example: hearing, visual, seizures, requiring a wheelchair etc.

Yes
No

Please list and describe any impairments:*

Does your child have any behavioural or social difficulties?*

For example: ADD, ADHD, ASD, anxiety etc.

Yes
No

Please describe how we can support your child if required:*

Does your child have any allergies or dietary requirements?*

Yes
No

Please list any allergies and dietary requirements:*

Patient-Specific Information

NOTE: If your child is currently on treatment or has been on treatment in the last six weeks, Challenge will require doctor approval.

Diagnosis*

Oncologist's name*

Date of diagnosis*

Is your child still on treatment?*

Yes
No

Date of last course of chemotherapy

Does your child have any neurological/muscular deficits or cardiac abnormalities?*

Yes
No

Please list and describe any neurological/muscular deficits or cardiac abnormalities:*

Does your child have a central venous device?*

For example: Broviac/Hickman or Port

Yes
No

Please list the central venous device:*

Has your child had any recent operations or serious illnesses?*

Yes
No

Please list and describe the recent operation(s) or serious illness(es):*

Medication details

If your child is successful in this application and requires medication, you will need to bring the necessary medication upon drop-off and ensure that all medications are clearly labelled and placed in a ziplock bag. Our nurse will receive, store, and administer the medications as directed.

Does your child have any medication requirements?*

Yes
No

Please write the medication instructions for your child, including: drug name, dose, days required, and time(s) of day required.*

Parent/Guardian details

Name

First Last

Relationship to child:*

For example: Parent, Guardian etc.

Contact email*

Medicare number (in case of an emergency)

Private health provider

Private health number

Emergency contact name*

First Last

Emergency contact number*

Family address

Street Address Suburb State Post Code

Consent Form

We regularly use photos/videos to showcase what this camp involves. Do you give Challenge permission to use your child(ren)'s photos/videos that they appear in for our website, social media, newsletter or other publications?*

Yes
No

If required, do you give consent for your child to be administered Paracetamol and/or any other non-prescription medication (i.e. Panadol, Zyrtec)?*

I confirm I understand and agree to the above.
I do not confirm or agree to the above.

Would you like the camp nurse to call you before administering any non-prescription medication?*

Yes
No

If we are unable to contact you or it is impractical to contact you, do you authorise the nurse/coordinator to consent to your child receiving any medical or surgical attention deemed necessary by a medical practitioner?*

Yes
No

I understand that if my child is successful, I must inform the Challenge staff if my child shows flu-like symptoms, such as a cough or runny nose.*

I confirm I understand and agree to the above.
I do not confirm or agree to the above.

Your signature below indicates approval of the following:

I permit my child to attend Challenge’s camp and participate in all activities offered during the camp. I acknowledge, agree and warrant that:

1. The information provided by me in this application is true and correct;

2. Challenge accepts no responsibility for the loss, damage or theft of property belonging to my child or myself;

3. I, for myself and my child, waive release, discharge and covenant not to sue Challenge, its officers, employees, volunteers or agents from any or all liability from any claims or demands resulting from personal injury, accident or illness (including death of myself or my child resulting from injury sustained at camp).

Signature