Slumber Party - Member Application Form

Applicant Information

Applicant's name:*

First Last

Date of birth:*

Gender:*

The applicant's t-shirt size:*

Has the applicant ever slept away from home?*

Yes
No

Has the applicant 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 the applicant attending this event 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 this event. All information is confidential and solely for the guidance of the Nurse.

Does the applicant have any physical impairments or limitations?*

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

Yes
No

Please list and describe any impairments:*

Does the applicant have any behavioural or social difficulties?*

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

Yes
No

Please list any beahvioural or social difficulties and describe how we can support the applicant if required:*

Does the applicant have any allergies or dietary requirements?*

Yes
No

Please list any allergies and dietary requirements:*

Patient-Specific Information

Diagnosis:*

Oncologist's name:*

Date of diagnosis:*

Is your child still on treatment?*

Yes
No

Date of last course of chemotherapy:*

Does the applicant have any neurological/muscular deficits or cardiac abnormalities?*

Yes
No

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

Does the applicant have a central venous device?*

For example: Broviac/Hickman or Port.

Yes
No

Please list the central venous device:*

Has the applicant had any recent operations or serious illnesses?*

Yes
No

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

Medication Details

If the applicant requires medication, please bring any medication required upon drop off. Please be sure that all medicines are clearly labelled in a zip lock plastic bag. The nurse will receive, store and administer the drugs as directed.

Does the applicant have any medication requirements?*

Yes
No

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

Parent/Guardian Details

Name:

First Last

Relationship to children:*

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 / Province / Region ZIP / Postal Code

Friend Details

Would the applicant like to bring along a friend?*

Yes
No

Friend's name:*

First Last

Friend's date of birth:*

Friend's gender:*

Does the applicant's friend have any medical conditions or medication requirements that Challenge should be aware of?*

Yes
No

Please list and describe any medical conditions or medication requirements:*

Does the applicant's friend have any physical impairments or limitations?*

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

Yes
No

Please list and describe any impairments:*

Does the applicant's friend have any behavioural or social difficulties?*

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

Yes
No

Please describe how we can support the friend if required:*

Does the applicant's friend have any allergies or dietary requirements?*

Yes
No

Please list any allergies and dietary requirements:*

Friend's emergency contact name:

First Last

Friend's emergency contact phone number:*

Consent Form

We regularly use photos/videos to showcase what this event 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 event 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 Challenge staff if my child is showing flu-like symptoms cough, runny nose, etc.*

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 event and participate in the activities provided as part of the event. 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 the event).

Signature*