2022 FUTURE LEADERS Camp Registration
15-17 year olds
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Email *
First name *
Last name *
Date of Birth *
MM
/
DD
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YYYY
Age *
Parent's Name *
Parent's mobile number *
Parent's email *
Home Address
Emergency Contact (name & number) *
Do you have any significant medical history? e.g surgery, injuries, serious illness. Please explain. (if none please write 'None') *
What medication must she take for this? (if applicable)
Do you have any dietary requirements? Please state below. (If none please write 'None') *
Are you a confident swimming in water? *
Required
Transport (Cost and details will be emailed to you) *
I heard about this camp through...
FOR PARENTS: I hereby consent to images/videos taken from the project that might feature my daughter, to be released for the purposes of media releases, reporting and promotion of the project. *
FOR PARENTS: I hereby consent my daughter to attend this camp and all the information submitted above is valid and true. *
A copy of your responses will be emailed to the address you provided.
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