2017 Belmont Intermediate School Camp Medical & Personal Information Disclosure
All information provided will be treated as confidential. The more we know, the better.

In order for Belmont Intermediate School (BIS) and Bigfoot to provide safe, enjoyable, quality experiences for all it is vital that we have as much information as possible about our participants. This information will not affect programme attendance, however, you/group leader/school/guardian/Bigfoot may need to put extra support in place or alter activity/programme to cater for specific needs.

It is essential that you give us accurate and detailed information. Please be open and honest about the smallest of things.
Where information is omitted or inaccurate, activity start may be delayed, or the participant may be unable to take part by Bigfoot or associated provider in order to meet our safety standards.

The dates for our camps are:

Camp 1 Rangitoto: Monday – Friday 6th - 10th March

Camp 2 Motuihe: Monday – Friday 13th- 17th March

Please complete and submit the following form by Monday 13 February

First Name
Your answer
Surname
Your answer
Participant's Gender
Participant's Team
Participant's 2017 Room number
Emergency contact 1 name
Your answer
Emergency contact 1 landline
Your answer
Emergency contact 1 work number
Your answer
Emergency contact 1 mobile
Your answer
Emergency contact 1 relationship to participant
Emergency contact 2 name
Your answer
Emergency contact 2 landline
Your answer
Emergency contact 2 work number
Your answer
Emergency contact 2 mobile
Your answer
Emergency contact 2 relationship to participant
Participant's Medical Centre / Local Doctor
Your answer
Medical Centre / Doctor's contact number
Your answer
Participant's dietary needs
Please provide details of any particular dietary needs e.g. gluten, lactose, vegetarian, vegan, halal. For specific food allergies please include detail of Allergen; Severity; Triggers; Symptoms; Remedy
Your answer
Participant's medical issues
Please provide details of any particular medical issues, e.g. asthma, epilepsy, diabetes, recent cold or illness, recent operation, heart or lung related, skin conditions, etc
Your answer
Participant's medication use or allergies
Please provide use details (dosage / ingredients / effects / inhibiters) of any current or recently finished courses of medication. For specific medicine allergy, please include detail of Allergen; Severity; Triggers; Symptoms; Remedy
Your answer
Participant's medication (this only requires an answer if above box is completed)
In accordance with the above, if your child requires any medication (for whatever reason) you agree to provide appropriate medication (in date) clearly labelled with instructions, doseage, etc.
Participant's intellectual, social, cultural, behavioural or other issues:
Please include in particular anything that may affect the participant’s understanding or perception of physical or emotional risk or ability to fully participate in the objectives of the programme e.g. Asperger’s; Recent family trauma; ADHD, etc.
Your answer
Participant's physical ability
Please include information on: Fitness levels; Old or New Injury; Operations, Restricted Movement, Hyper/hypo Mobility, Conditions, Wheelchair use etc.
Your answer
Participant's swimming ability
Participant's comfort with tight, enclosed spaces
Participant's comfort with heights
Participant's attitude to challenge
Participant's previous experience with any of the activities planned in this awesome Bigfoot Adventure.
e.g. kayak at the beach all summer; go hiking with my mates a few times a year; surfing while on holiday, etc.
Your answer
Do you wish for the school or a Bigfoot Representative to contact you regarding any information you have provided above?
I am confirming that the information provided is as accurate and complete as possible. I understand that where information is omitted or inaccurate, activity start may be delayed or my child may be stood down by Bigfoot or associated provider in order to meet our safety standards.
Any other information BIS or Bigfoot should be aware of regarding your child's participation at camp
ie: anything you would like to mention, that has not been covered in the questions above
Your answer
I approve of my child attending the Belmont Intermediate School Year 8 camp at Waipu Cove in 2017. In the event of an accident or illness, I authorise the obtaining of such medical assistance as may be required. I hereby certify that my child has no physical disability, nor is he / she suffering from any complaint that is likely to prove detrimental to him / her or others while on the camp. I understand that there are risks associated with involvement in school EOTC events and that these risks cannot be completely eliminated. I understand that the school will identify any foreseeable risks or hazards and implement correct management procedures to eliminate, isolate or minimise those hazards. I will do my best to ensure that my child follow these procedures. I understand that the school does not accept responsibility for loss or damage to personal property and that it is my responsibility to check my insurance policy.
Required
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