Amp Camp 2018 - March 9-11th - LEADERS APPLICATION
A camp hosted by the Amputee Association of Sydney for Australian youth aged 12 years and over with amputation, limb loss or limb difference.
CAMP DIRECTOR: RUSSELL HODGE
email contact: russell@cornerstone.edu.au // mobile: 0412 57 37 88
Venue: Teen Ranch, 352 Cobbitty, NSW 2570. Tel: 02 46512268 Web: www.teenranch.com.au


This form is to be completed by Volunteers seeking to participate as leaders in the 2018 Amp Camp. In submitting this form you are declaring your acceptance of the conditions outlined below and contained within the form.

Risk Warning: I understand that recreational activities organised by Teen Ranch Limited may include horse riding, canoeing, abseiling, and low and high ropes courses. These and other recreational activities arranged from time to time are of their nature inherently dangerous. I understand that Teen Ranch is accredited by the Australian Camping Association, which means its camps comply with Australian industry best practice contained in the standards set by that organisation.

In submitting this application form I acknowledge that the paragraph above constitutes a risk warning under the terms of the Civil Liability Act 2002 (New South Wales), and I/we hereby release Teen Ranch and the Amputee Association of Sydney, their officers, employees and volunteers from liability to the extent permitted under the terms of that Act.

Medical Assistance: In the event of an emergency I authorise the Camp Director to obtain all necessary medical assistance, including ambulance transport and hospital accommodation, and I agree to pay for all related fees and expenses.

Queries: Contact Russell Hodge 0412 573 788

PLEASE NOTE: Amp Camp 2018 has an OPTIONAL Extra Day - Monday 12th March
Have to work? Take a day off! (no not a sickie) - A Flexi??? Leave without pay??? Plan it NOW!
Your Details
Name *
First and Surname
Your answer
Sex *
Required
Date of Birth *
MM
/
DD
/
YYYY
email *
Your answer
Mobile Phone Number *
(or best contact number)
Your answer
Postal Address *
Please provide full Postal address including State & Post Code
Your answer
Health Info & Emergency Contact
Emergency Contact *
Your answer
Best Contact Number *
Your answer
Medicare Number Including Card Ref No *
Your answer
Medicare Expiry Date *
Your answer
Limb Difference / loss or amputation and related special needs *
Please describe in detail eg Right Above Knee Amputee or if none N/A
Your answer
Other Information
Special Dietary Requirements *
Required
If Yes please specify
Your answer
I will be able to stay for Monday 12th *
Required
A complimentary camp T-Shirt may be provided. Please select the preferred shirt size. *
Required
Working with Children Checks *
Please provide your current NSW WWCC clearance number or State equivilent
Your answer
Please include a few lines explaining why you want to be part of the Amp Camp Leadership Team: *
Your answer
Amp Camp Contribution *
Amp Camp is a volunteer Peer Support Camp. Financial hardship does not exclude people from volunteering for Amp Camp. Please keep in mind however that Amp Camp does cost. Upon approval as an Amp Camp leader you will receive an email concerning Camp Contributions. Please consider the options below that best describe your situation:
Required
Camp Contribution
Please select your preferred payment option and forward the Amp Camp Contribution as soon as possible. This application will be processed once the deposit has been received. When paying by Direct Deposit please use campers name as deposit identifier.
AMP CAMP LEADERS COMMITMENT *
In making this application I am committing myself to the following:
Required
Travel Assistance Request - for Interstate and Rural Volunteers
Should your travel assistance request be successful, reasonable vehicle and flight costs incurred during travel to camp may be paid by the Amputee Association of Sydney. The travel Coordinator will assist in making necessary arrangements such as airport transfers. It is our vision to enable youth from all over Australia to attend the 2016 camp. Every effort will be made to assist leaders requiring travel assistance, however, please be aware that travel assistance priority is given to campers. Please contact us if you require any assistance or further information.

Travel Coordinator - Therese Howell P: 0439905533 E: rthowell@netspace.net.au

Required Travel Information
Distance
Travel Requirements
Airport Info: Preferred Departure Flight Airport
Your answer
Airport Info: Preferred Return Flight Airport
Your answer
Return Travel Dates
Personal Requirements
Please detail any other travel requirements you may have:
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of Cornerstone Community. Report Abuse - Terms of Service - Additional Terms