REVIVAL CENTRES CHURCH YOUNG REVIVALISTS’ CAMP 2017

APPLICATION FORM OVER 18 YEARS OLD

EVENT

Senior Camp ($375) Sat Sept 23rd - Wed Sept 27th

Junior Camp ($325) Wed Sept 27th - Sun Oct 1st

Both Camps ($580) Sat Sept 23rd - Sun Oct 1st

PERSONAL DETAILS

Surname: Preferred First Name:

Home Address:

Suburb: Postcode:

Email: Contact Phone:

Date of Birth: Gender: Male Female

Medicare No: Family Seq. No: Expiry date:

Private Health Cover? Provider Name: Provider Number:

Ambulance Member? Ambulance Number:

EMERGENCY CONTACTS

Details of a person we can contact if you require medical attention

Name: Relationship:

Address:

If we cannot contact you in emergency, who should we call?

Name: Relationship: Contact Phone:

CAMP INFORMATION

I have a valid Working with Children check; please attach a copy with your application (mandatory for all attendees over 18 years old)

Spirit Filled? Assembly:

I have been already previously assembly responsibilities

How would you like to be involved? Team Leader/Assistant Activity Leader General Asistant

Room allocation: List three people you would like share with

1. 2. 3.

I will be bringing a Musical Instrument to camp

I will be travelling by Bus to/from Camp leaving from Boxhill hall. If not, how you will be travelling to camp

Please list any skills, interests or qualifications which may be useful in planning activities

I hold a current First Aid Certificate

I would be interested in becoming First Aid certified before camp

PASTOR / AREA LEADER SIGNED

The applicant is a regular member of our Assembly, and in my opinion will be an asset to the camp

Signature: Print Name:

REVIVAL CENTRES CHURCH YOUNG REVIVALISTS’ CAMP 2017

APPLICATION FORM OVER 18 YEARS OLD

HEALTH STATEMENT

Please disclose if you suffer from any chronic or recurrent ailment, allergy or physical incapacity

Do you suffer from

Asthma Dizzy Spells or Black Outs? Travel Sickness (bus)

Diabetes Bed Wetting Migraine Headaches

Epilepsy Sleep Walking

I suffer from known Allergies (e.g. nut, penicillin, bee stings, bites, egg, hay fever, other food, drugs). Please specify

I am a known anaphylaxis risk I will bring an Epipen to camp

What other information about you should we be aware of? (e.g. dietary requirements)

Analgesics: In the event that you require administration of an analgesic (e.g. Panadol), you will need to provide your own

Details of last Anti-Tetanus injection Year of Original Injection: Year of Last booster injection:

LEADERS / ASSISTANTS AGREEMENT

I am aware of the importance of setting a good example to the children in my care. I agree to follow all camp rules and support other leaders and the oversight. I am prepared to devote myself wholly to the children and to help encourage their involvement in the camp. I will attend Leader/Administration meetings and discussion times arranged by the camp organisers.

In the event of any accident or illness, I authorise the obtaining on my behalf of such medical assistance as I may require. I also undertake to pay medical fees and/or cost of drugs that may be incurred while I am on a Revival Centre Church activity. The Revival Centres Church and its agents shall not be liable or responsible for any injury, loss or damage caused by or to any participant's property, whether or not such injury, loss or damage results in part or whole from any negligence, carelessness or incompetence on the part of Revival Centres or its agents. I declare that I am not a person prohibited by any Act or law from seeking, undertaking, or remaining in child-related employment.

I have read, understood and agree to all the foregoing.

Name: Signature: Date:

MEDIA STATEMENT

During camp, photographs and/or video footage of you may be taken and used during camp activities, placed on the RCC website or Facebook page and may be used at Sunday meetings to promote camps

I do not want my image used to promote camps

PRIVACY STATEMENT

Protecting your privacy and your personal information is an important aspect of the way the Revival Centres Church operates. We will only collect personal information from you with your prior knowledge and consent. We will only use personal information provided by you for the purposes for which it was collected. We will not disclose your personal information to a third party*. We ensure that your personal information will not be disclosed to other authorities except if required by law or other regulations. We will remove personal information from our system where it is no longer required. (Except where archiving is required)

*As the camp is fully catered, any special dietary considerations will be passed on to the staff at Weekaway.