YGC Camp Registration - Westminster Presbyterian Church Bull Creek

Activity disclosure

The Camp is an activity of Westminster Presbyterian Church. The activities include but are not limited to: talks and organised activities.

Name of Person Attending *

First

Last

Contact Number *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Email *

Gender *

Male
Female

Date of birth *

Is the person you are registering under 18? *

Yes
No

Under 18 Medical Form and Authorisation Form

Medicare Card Number *

Please include position number i.e 1, 2 3 etc

Medicare position number e.g 1,2,3 *

Do you have a Private Health Fund? *

Yes
No

Name of Health Fund Provider *

Health Fund Number *

Health Fund position number e.g 1,2,3 etc *

Do you have ambulance cover? *

Yes
No

Allergies

Does the attendee have any allergies? *

Yes
No

Select any allergies that apply *

Please list food allergies *

Please list other allergies *

Is the person attending required to carry an Adrenalin Pen? *

Yes
No

Does the person attending have any medical conditions? *

Yes
No

Please select any medical conditions that apply *

Asthma
Diabetes
Other

Please list other medical conditions *

Does the person attending need to use regular medication? *

Yes
No

Please list any medication that required self-administration *

Emergency Contact Information

Contact person in case of emergency *

Relationship to child *

Emergency contact number *

Alternative contact person in case of emergency

Relationship to child

Emergency contact number

Consents

I consent that WPC Bull Creek may use photos and/or video footage of my child/ward for the WPCBC website/newsletter/other publications *

Yes
No

I 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 *

Yes

I 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 *

Yes

Indemnity

In my child/ward attending this WPCBC camp, I undertake the following:

Checkboxes *

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 behlf 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 ir related t any forseeable loss, property damage or personal injury that may be sustained by my child/ward or to any property belongng 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.

Indemnity

In attending this WPCBC camp, I undertake the following:

Checkboxes *

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.
I accept all reasonably forseeable risks associated with the WPCBC camp program and activities. I acknowledge that this acceptance is a condition precedent to my taking part in any capacity in the WPCBC Camp program and activities.
I hereby 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 myself or to any property belonging to myself 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 myself 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 *