WSA Youth Retreat 2019- Registration Form
The WSA Youth 2019 will be held at Mount Keira Girl Guide camp from the 31st May to 2nd June.

Please register below before May 3rd.

For more information please visit wollongongsalvos.org.au/youth

Attendee Type *
Date of Birth *
MM
/
DD
/
YYYY
First Name *
Your answer
Last Name *
Your answer
Gender *
Street Address *
Your answer
Suburb *
Your answer
Post Code *
Your answer
Email Address *
Please note the email address noted here will be where all communication will be sent to
Your answer
Emergency Contact Full Name *
Your answer
Emergency Contact Number *
Your answer
Relationship to Camper *
Your answer
Languages Spoken at Home *
Your answer
Camper's Medicare Number *
Your answer
Reference Number on Medicare Card *
Your answer
Expiration Date of Medicare Card *
MM/YYYY
Your answer
Family Doctor *
Your answer
Family Doctor Phone Number *
Your answer
Does the camper have any food allergies or intolerances? If yes, please provide details (noting if traces of products is acceptable/not acceptable) *
If not applicable please put N/A.
Your answer
Does the camper have any other allergies? (Please include list of allergies, severity and action plans in this text box) *
If not applicable please put N/A.
Your answer
Does the camper have any medical conditions? (Please include details on the condition and treatment plan i.e. what the appropriate action plan is) *
If not applicable please put N/A.
Your answer
Is there any other information that would help us provide the best possible care for the camper (such as disabilities, activity restrictions or behavioural issues)? *
If not applicable please put N/A
Your answer
Is the camper currently using prescribed or any drugs of dependence (i.e. medication)? *
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