Surf Camp - Member Application Form

Applicant/Camper Information

Applicant'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

What is your child's swimming ability (poor (0M), fair (<50m), good (50-100m), very good (100-200m), excellent (200m+))?*

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 camp we should know about (e.g. sleeping habits, etc.)?

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 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 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 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

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. Some of the activities involved may include for example a water skill (surfing, knee boarding, wake boarding, skiing, biscuiting/tubing), and swimming. I understand the potential risks involved to my child or myself in the nature of said activities;

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

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