Going Further 2018 Registration
By filling in this form, an invoice will be sent to you within a few weeks. Payment can then be made by bank deposit or cheque. Payment must be received no later than 1 Feb 2018
Name *
Your answer
Gender *
Age *
Your answer
Mobile Number *
Your answer
Email Address *
Your answer
Church *
Your answer
Dietary Requirements
Your answer
Emergency Contact Info
Who do we contact if there is an emergency
Your answer
Billing Address
Name and Address *
Your answer
If you would be willing to assist with corporate worship, tell us what instrument you could bring and play or what other ways you could contribute to worship i.e dance spoken word poet three art etc.
Your answer
Medical History
As we will be in an isolated environment for several days it is very important that you provide us with any medical information that we may need to know to look after you. Please fill in this section to the best of your ability. Your medical history will be kept confidential.
Please detail if you are currently under medical care for any conditions
Your answer
Please detail any operations or serious injuries in the past 2 years
Your answer
Please detail any chronic or recurring illness or medical condition
Your answer
Please detail any special health and behaviour considerations
Your answer
Health History
Please tick all that apply
Please give any relevant details about the item you have checked, i.e medication required etc
Your answer
Allergies
(food, drugs, plants, insects)
Please give any relevant details about the item you have checked, i.e medication required etc
Your answer
RECOMMENDATIONS & RESTRICTIONS WHILE AT CAMP
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Any treatment to be continued at camp
Your answer
Any medication to be administered at camp (must be in original containers with specific dosages)
Your answer
Any medically prescribed meal plan or dietary restrictions
Your answer
Additional Health Information / Activities to be limited
Your answer
AUTHORISATION
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*
Required
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