First Name *

Last Name *

DOB *

Age *

Mobile *

Emergency contact (name & number) *

I want to be a camp leader because...

I heard about being a leader through...

City of residence *

I am currently... *

Do you have any dietary requirements?

Are you a confident swimmer? *

I can make it to these Leader Trainings... *

I can assist with transport...

I hereby consent to images/videos taken from the project that might feature me, to be released for the purposes of media releases, reporting and promotion of the project. *

I hereby certify that the above statements are true and correct to the best of my knowledge.