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Join
Calendar
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Who We Are
About Challenge
Who We Are
What We Do
Leuk the Duck
Membership
Become a Challenge Member
About Membership
Challenge Membership Form
Sibling Membership Form
Member Stories
Our Programs
Emotional Support
Art Therapy
Massage Therapy
Music Therapy
Parent Support
Practical Support
The Challenge Family Centre
Holiday Accommodation
Hospital Support
Scholarships and Trusts
Social Support
Activities and Outings
Camps
Playgroup
Get Involved
Challenge Fundraising Campaigns
#DoingItForJarrod
A Day in May
KTM Ride4Kids
Tackling Childhood Cancer
Challenge Fundraising Gala Events
Challenge Ball
Diamonds Are A Girl’s Best Friend
Robert Allenby Golf Day and Gala Dinner
Community Fundraising
Biggest Aussie Pie Night
Golf Days
Leuk the Duck™ Merchandise
Lace up for Challenge
Volunteer
Volunteer with Challenge
Donate
News
Shop
Contact Us
Donate
Slumber Party - Member Application Form
If you are a Challenge member and patient who would like to attend the Challenge Slumber Party, please fill in the form below:
Applicant Information
If there is any chance your child has come into contact with a contagious disease (such as Colds, Flu or Chicken Pox) before attending camp, it is in the interest of other Challenge members that you notify the office as soon as possible on 9329 8474.
Applicant's name
*
First
Last
Date of birth
*
DD slash MM slash YYYY
Gender
*
Your child's t-shirt size
*
Has your child ever slept away from home?
*
Yes
No
Has your child had any recent contact with any contagious diseases, such as chicken pox, measles? If yes, please describe:
*
Any other concerns regarding your child attending this event we should know about (e.g. sleeping habits, etc.)?
Is the applicant fully vaccinated against covid-19?
*
Yes
No
Are you able to show proof of vaccination?
*
Yes
No
Medical Information
A Nurse will be on full-time duty during the trip. All information is confidential and solely for the guidance of the Nurse. If a sibling or friend is attending, please detail if any medical information is needed.
Does the applicant have any vision/hearing impairments or convulsions/seizures?
*
Yes
No
If yes to the above, please describe:
Any other allergies, dietary requirements, physical limitations, behavioural/social difficulties?
Patient-Specific Information
NOTE – If your child is currently on treatment or has been on treatment in the last 6 weeks, we will need a doctor approval form to be signed by your oncologist. This form will be sent out to you if your child’s application has been successful for final confirmation.
Diagnosis
*
Oncologist's Name
*
Date of diagnosis:
DD slash MM slash YYYY
Is your child still on treatment?
*
Yes
No
Date of last course of chemotherapy:
DD slash MM slash YYYY
Does your child have any neurological/muscular deficits or cardiac abnormalities? If yes, please describe.
Does your child have a central venous device (for example, Broviac/Hickman or Port?)
Yes
No
If yes, please describe:
Describe any recent operation(s) or serious illness:
Medication details
If your child 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.
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 children (parent/guardian):
*
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
Address Line 2
Suburb
State / Province / Region
ZIP / Postal Code
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Panama
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Uganda
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Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Consent Form
Do you give Challenge permission to use your child(ren)'s image in print or film in Challenge Newsletters or Social Media?
*
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 and understand to the above.
I do not confirm or agree to the above.
Would you like the nurse present at the event 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
My child or immediate family has not come into contact with anyone with a contagious disease, including cold, flu, chicken pox, measles or COVID 19. I understand I must inform challenge staff if my child is showing flu-like symptoms cough, runny rose, etc
*
I confirm and understand 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 trip and participate in the activities provided as part of 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. Challenge has permission to use my child’s image or likeness or voice in print or on tape or film in Challenge Newsletters, social media or other publications;
4. 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
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