Young Adults Camp Registration Form 2021 Dates: 26-28 March. Venue: Orchard Glory Farm Resort, 41 Mooliabeenee Road, Bindoon WA 6502 Please enable JavaScript in your browser to complete this form.Activity disclosureThe Young Adults Camp is an activity of Westminster Presbyterian Church. The activities include but are not limited to: talks and organised activities.Registration TypeStudent $130Employed $160Payment DetailsPayment Details BSB: 306-085 Acc: 4195782 Narration: YAC21 and your first name and last name (eg. YAC21 JSmith)Name of Person Attending *FirstLastContact Number *Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwan, Province of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)Viet NamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryEmail *Gender *MaleFemaleDate of birth *Is the person you are registering under 18? *YesNoUnder 18 Medical Form and Authorisation FormMedicare Card Number *Medicare position number e.g 1,2,3 *Do you have a Private Health Fund? *YesNoName of Health Fund Provider *Health Fund Number *Health Fund position number e.g 1,2,3 etc *Do you have ambulance cover? *YesNoAllergiesDoes the attendee have any allergies? *YesNoSelect any allergies that apply *PenicillinBee stingsBetadinePain relief medicationFood allergiesOtherPlease list food allergies *Please list other allergies *Is the person attending required to carry an Adrenalin Pen? *YesNoDoes the person attending have any medical conditions? *YesNoPlease select any medical conditions that apply *AsthmaDiabetesOtherPlease list other medical conditions *Does the person attending need to use regular medication? *YesNoPlease list any medication that required self-administration *Emergency Contact InformationContact person in case of emergency *Contact person in case of emergency *Relationship to child *Relationship to you *Emergency contact number *Emergency contact number *Alternative contact person in case of emergencyRelationship to childEmergency contact numberDo you have any special dietary requirements? *YesNoDietary RequirementsConsentsI consent that WPC Bull Creek may use photos and/or video footage of my child/ward for the WPCBC website/newsletter/other publications *YesNoI consent that WPC Bull Creek may use photos and/or video footage of me for the WPCBC website/newsletter/other publications *YesNoI authorise the WPCBC leaders/volunteers, ministers, elders, deacons in charge, where it is impractical to communicate with me, to arrange for medical treatment for my child/ward as deemed necessary by a qualified medical practitioner *YesI authorise the WPCBC leaders/volunteers, ministers, elders, deacons in charge, where it is impractical to communicate with me, to arrange for medical treatment for me as deemed necessary by a qualified medical practitioner *YesI authorise the use of ambulance for my child/ward should it be deemed necessary and authorise the use of anesthetics by a qualified medical practitioner if in his/her judgment it is deemed necesary *YesI authorise the use of ambulance for me should it be deemed necessary and authorise the use of anesthetics by a qualified medical practitioner if in his/her judgment it is deemed necesary *YesIndemnityIn me/my child/ward attending this WPCBC camp, I undertake the following: *I, the undersigned agree that in the event of my child/ward requiring medical attention, I acknowledge that any costs incurred will be my responsibility and I agree to reimburse Westminster Presbyterian Church Bull Creek inc (WPCBC) and its employees and/or volunteers for all costs which they incur on my child/ward's behalf. I agree that my child/ward will abide by the rules, guidelines and instructions given by Westminster Presbyterian Church Bull Creek Inc and/or its employees, volunteers, ministers, elders, deacons in charge, in respect of the activity.I have read and fully understand the medical form and authorisation. In consenting for my child/ward to attend the WPCBC camp program and activities, I accept all reasonably forseeable risks for my child/ward associated with the WPCBC camp program and activities. I acknowledge that this acceptance is a condition precedent to my child/ward taking part in any capacity in the WPCBC Camp program and activities.I hereby, on behalf of my child/ward release, hold harmless and forever discharge WPCBC Camp, WPCBC camp leaders and church leaders against any claim whatsoever arising out of or related to any forseeable loss, property damage or personal injury that may be sustained by my child/ward or to any property belonging to my child/ward while in attendance of the duration of the camp. I agree that this document may be pleaded in bar to any claim arising from risks normally associated with the activity, made by or on behalf of my child/ward or my executors, administrators or other personal representatives arising out or in respect of the WPCBC church and its ministries.The indemnity and release contained in this document will be enforceable against me and my executors, administrators and other personal representatives. I certify that the particulars given above are correct.In attending this WPCBC camp, I undertake the following: *I, the undersigned agree that in the event of requiring medical attention, I acknowledge that any costs incurred will be my responsibility and I agree to reimburse Westminster Presbyterian Church Bull Creek inc (WPCBC) and its employees and/or volunteers for all costs which they incur on my behalf. I agree that I will abide by the rules, guidelines and instructions given by Westminster Presbyterian Church Bull Creek Inc and/or its employees, volunteers, ministers, elders, deacons in charge, in respect of the activity.In consenting to attend the WPCBC camp program and activities, I accept all reasonably forseeable risks associated with the WPCBC camp program and activities. I acknowledge that this acceptance is a condition precedent to me taking part in any capacity in the WPCBC Camp program and activities.I hereby, hold harmless and forever discharge WPCBC Camp, WPCBC camp leaders and church leaders against any claim whatsoever arising out of or related to any forseeable loss, property damage or personal injury that may be sustained by me or to any property belonging to me while in attendance of the duration of the camp. I agree that this document may be pleaded in bar to any claim arising from risks normally associated with the activity, made by or on behalf of me or my executors, administrators or other personal representatives arising out or in respect of the WPCBC church and its ministries.The indemnity and release contained in this document will be enforceable against me and my executors, administrators and other personal representatives. I certify that the particulars given above are correct.Signature *Clear SignatureNameSubmit If you need to register another person click here