2017AUTUMN VISION YOUTH CAMP
REGISTRATION FORM
Parent/guardian to complete. This document is accessible.
First, we need you to click the link below and fill the mandatory online medical consent
Booking number:515505
Start Date: 19/04/17
Booking Venue: Milson Island Sport and Recreation Centre Name of Organisation: Blind Sports NSW
You will also need to complete the below form and email through to:
CONTACT DETAILS OF CAMP PARTICIPANT
Participant’s last name:
Participant’s first name:
Address:
Male Female
Date of birth:Click here to enter text.
CONTACT DETAILS OF PARENT / GUARDIAN
Names of parent / guardian:
Address:
Home Phone:
Work phone:
Mobile:
Email:
Relationship to camp participant:
Parent
Guardian
Grandparent
family member
other
CONTACT DETAILS OF DOCTOR
Name:
Address:
Phone #1:
Phone #2:
Mobile:
EYE CONDITION
If you are not sure, please put N/A for any of the fields
Name of eye condition:
Glasses: YES / NO
Contact lenses: YES / NO
Prosthesis:YES / NO
Cane:YES / NO
Guide Dog:YES / NO
Does your child require alternate format for print? YES / NOLarge Print size:
Uses Braille: YES / NO
Visual Acuity: Left eye: Right eye: Binocular:
Visual Field: Left eye: Right eye:
Other information:
TRAVEL ARRANGEMENTS
Please note: Milson Island can only be accessed via boat. The parent / guardian is responsible for the co-ordination of transportof campers to and from Brooklyn Wharf. (Directly opposite Hawkesbury Train Station). If transport assistance is needed, please contact us o makearrangementsas soon as possible aswe have only 10 spaces available on our bus.
Camp participant will be dropped off by:
Name:
Phone:
Camp participant will be picked up by:
Name:
Phone:
PAYMENT INFORMATION
AU$200.00 camp fee* payment can be made by bank transfer to the following account:
Bank: Commonwealth Bank Name: Blind Sporting Association of NSW
BSB: 062-005 Account Number: 00906804
Please send payment receipt/confirmation
*Payment is due April 6th.
Bottom of Form
HEALTH AND MEDICAL INFORMATION
Medicare Number:
Position on card:
Valid until:
Private health insurance fund:
Number:
Disability Support Pension (Blind) number:
Does the camp participant suffer from the following? (please tick) (if yes to any below, please attach details as required)
Chronic illness
Any allergic condition
Anaphylaxis (provide anaphylaxis management plan)
Asthma (provide asthma plan)
Bed wetting
Attention deficit disorder (ADD / ADHD)
Behavioural problems
Social or emotional difficulties
Diabetes
Epilepsy
Sleep walking
Skin condition
Fears or phobias
Other:
Does the child have any other disability other than vision impairment? YES / NO. If YES, provide details:
In relation to the proposed water or swimming activities, I advise that my child is a: (please circle)
strong swimmeraverage swimmer poor swimmernon-swimmer
Does the child have any social or emotional difficulties that may affect his/her enjoyment of camp? YES / NO. If YES, provide details and any strategies that would assist the participant in managing these difficulties and the participant’s current behavioural management plan.
Provide details of current medications required during camp and instructions for administration:
Does the camp participant have any special requirements and dietary needs? YES / NO. If YES, provide details: eg. Diet, wheelchair access etc.
(This should have also been filled in at the medical consent form you completed with Sport & Recreation)
Has the camp participant had a recent combined Diptheria Tetanus Toxoid booster injection?YES / NO. If YES, what year?
Has the camp participant been immunized against measles? YES / NO. If YES, what year?
Is your child currently under medical treatment? YES / NO. If YES, provide details:
EMERGENCY CONTACT DETAILS X 2
The emergency contact people will be the participant’s 24 hour contact. They must have transport and be able to collect the participant at any time. PLEASE NOTE: We cannot accept a Helpline Number.
First Contact Person:
Relationship to Camper:
Email:
Home phone:
Work phone:
Mobile:
Second Contact Person:
Relationship to Camper:
Email:
Home phone:
Work phone:
Mobile:
OTHER
Please attachwith this Registration Forma photo of the Camp participant, for identification purposes by staff.
Parents and guardians may participate in pre and post camp activities such as settling in / orientation to camp and the concluding awards ceremony.
What is your preferred means of communication between the Camper and parent / guardian during Camp:
Camper’s T-shirt size:
How did you hear about the Blind Sports Camp?
For more information, please contact the Camp Coordinator,Murray / Tami
- phone0427 186 734 or 0431 268 561
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