April 10 to 12 at 21 at Baden Powell Scout

Thunderbird Park 8th- 10th January

April 10 to 12 at 21 at Baden Powell Scout

Child or Young Person's Name: / First / Middle / Surname
Address
Date of Birth: / Gender: / Age:
Country of Birth: / City or Town of Birth: / Aboriginal Yes/No / Torres Strait IslanderYes/No
Medicare Number:
Health Care Card Number:
Emergency Contact; / Relationship to Child or Young Person:
Phone: / Mobile:
Child or Young Person's Legal Guardian: / Is the Child or young person in Voluntary Out Of Home Care? / Is the Child or Young Person in Statutory Out Of Home Care?
Does the Child or Young person have a Caseplan: / Caseworker: / Organisation: / Contact Details:

Medical Information

Does the young person suffer from any medical conditions?Or allergies?Yes/No

If "yes", please provide further details:

Does the young person have a disability?Yes/No

Does the young person have any special dietary requirements?Or food allergies?Yes/No

If "yes", please provide further details:

Does the young person require additional support eg. Showering/dressing/eating/toileting? Yes/ No

If "yes", please provide further details:

Does the young person have any behavioural difficulties?Yes/No

If "yes", please provide information relating to the young person's behaviours and recommended strategies:

Can the young person swim 25 metres?Yes/No

Has the young person had a tetanus shot Yes/No

If so when:

Current Medication

Please note: All medication must be supplied in a WEBSTER PACK and given to the camp leader when the young person is dropped off.

Does the young person take any current medication?Yes/No

If yes please fill in details below:

Name of Medication / Breakfast / Lunch / Before Bed
Time / Dosage / Time / Dosage / Time / Dosage

Authority to administer medication:

I give consent for a SNAP Camp leader to administer medication to:

______Signature

______

(Print name)Relationship

Snap Camp Permission Form

I ______give permission

(Insert Person Responsible i.e. Parent or Carer)

for ______to attend theSNAP Holiday Camp

(Insert Young Person’s Name)

held at ______on ______

(camp site) (date from –to)

I understand that the child or young person will be participating in a range of activities including, swimming, camp fire and other camp activities.

______Date ____/_____/_____.

(Signature)

Camp Cost $640 plus GST

Please send payment before commencement of camp. All Cancellations made within 7 days of the camp commencement date will receive a 50% cancellation fee

Please make all payments to SNAP Programs Limited (ABN) 36 155 441 357

Send cheques or money orders to PO Box 2436, Dangar NSW 2309,

or electronic transfer to National Australia Bank BSB 082514 Acct# 129472797

Please include your invoice number or email remittance to

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