Medical & Personal Information Form - The Journey 2018
Adventure Lodge - Mon 3rd - Wed 12th December 2018
Medical & Personal Information Form - CONFIDENTIAL
PROTECTING YOUR PRIVACY - The information we seek allows us to manage risk, and provide reasonable care in our camp. We are careful to keep any sensitive information confidential, and provide it only to team members who need it on camp (e.g. designated first aider) - we will not use this information for other purposes.
Personal Name *
Your answer
Family Name *
Your answer
Preferred Name
Your answer
*
Date of birth *
MM
/
DD
/
YYYY
Address
Your answer
City/Town
Your answer
Postcode
Your answer
Home Phone *
Your answer
Moblie
Your answer
Email
Your answer
Do you consent to these details being included on a contact list provided to participants? *
Emergency Contacts
In case of an emergency, please list phone numbers where you (parent/caregiver), and at least one other person (a friend or relative), may be contacted during the course of the camp.
Parent/Caregiver Name *
Your answer
Relationship *
Your answer
Day Phone *
Your answer
Night Phone *
Your answer
Mobile Phone *
Your answer
Friend/Relative Name
Your answer
Relationship
Your answer
Day Phone
Your answer
Night Phone
Your answer
Mobile Phone
Your answer
Travel Information
The camper will ARRIVE by:
Expected arrival time
MM
/
DD
/
YYYY
Time
:
Arrival location
*if arriving by car please include name of driver.
Your answer
The camper will DEPART by:
Expected departure time
MM
/
DD
/
YYYY
Time
:
Departure location
*if departing by car please include name of driver.
Your answer
Medical and Dietary Information
Dietary Requirements *
Please give additional details for dietary concerns
Your answer
Doctor's name
Your answer
Doctor's Phone Number
Your answer
Medications
Our team members DO NOT supply medications (e.g. paracetamol).
Do you anticipate the camper will need to take ANY tablets or other medication during the camp? *
List any medication you are supplying along with the dose, timing, and reason for it.
IF you wish the camper to self-administer medication, you MUST explain.
Your answer
Has the camper been taken off medication recently? *
If YES please give details:
Your answer
Has the Camper previously broken/fractured any bones? *
If YES please give details:
Your answer
What is the year of the camper's last teanus injection?
Your answer
Specific Medical Conditions
Please indicate below, if the camper has had any of the following. Provide additional details if necessary.
In the Past
Present
Asthma
Diabetes
Epilepsy
Fits/Convulsion
Faint/Dizziness
Hyperactivity
Hypo activity
Heart Problems
Allergy - Foods
Allergy - Animals
Allergy - Other
Details
(e.g. severity; last injection; treatment)
Your answer
Are there any conditions requiring special attention that we should know about? *
(e.g. hearing or sight impairment; reading or learning difficulties; ADD or ADHD; behaviour issues; formal counselling situations; other)
Details
Your answer
I consent to appropriate use by Capernwray NZ of photographs or video that include the camper *
Appropriate use includes inclusion in a CNZ newsletter, placement on a CNZ webpage or in a CNZ brochure. In all cases including minors only photos and video that do not easily identify individuals will be used. However, we can take no responsibility for participants personal uploading to social media, such as Facebook or Twitter.
Camper Agreement with Capernwray Bible School
I, the Camper, agree to observe the rules and routines of camp, and to participate in the programme arranged. *
Parent / Caregiver Agreement with Capernwray NZ - IF CAMPER IS UNDER 18
BY CLICKING ON THE SUBMIT BUTTON I AGREE TO THE FOLLOWING:
· I give permission for (my child/the child in my care) to attend the camp.
· I am aware that certain aspects of the programme may be physically and emotionally demanding.
· I understand that certain inherent risks and dangers may exist in the activities in which the camper will take part. I acknowledge that, while Capernwray NZ and its leaders will make every reasonable effort to minimise exposure to known risks, some hazards and dangers associated with these activities cannot be foreseen or may be beyond the control of Capernwray NZ and its team.
· In the EVENT OF ANY EMERGENCY where the camper’s emergency contact people are unavailable:
1. I authorise the team to obtain medical advice and/or assistance that they deem necessary.
2. I further authorise qualified practitioners to administer anaesthetic if required.
3. I accept all operation, blood transfusion and/or anaesthetic risks involved in the event that such procedures are deemed necessary.
4. I accept the responsibility for payment of any medical, transport or other related expenses.
· I consent to the camper’s personal information being securely held by Capernwray NZ for the purposes of appropriate care during the camp and contact details retained only for corresponding about the current camp and notification of future events.
· I confirm that the information given is true and correct, and I will advise the Team Leader promptly of any changes.
Submit
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