Edmund Rice Camps Dunedin - Children's Application Form
This application form MUST be completed for acceptance on Edmund Rice Camps Dunedin, all information will be kept confidentially and will be held by the Camp Captains during camp.
Email address *
Referring Agency Information - To be completed by referrer.
Name of agency
Your answer
Person referring
Your answer
Work Phone
Your answer
After hours phone
Your answer
I have read the following terms and agree with the following
Should the child need to be sent home due to illness or inappropriate behaviour, it is the referral agent's responsibility if parents/carers are unable to provide transport.
Why are you referring the child to ERC?
Your answer
Camp applying for;
You can choose all that apply
ALL SECTIONS MUST BE FILLED OUT. This MUST be filled by/with the Child's Caregiver *
Child's first name
Your answer
Child's preferred Name
Your answer
Last name *
Your answer
Gender *
Your answer
Home address *
Your answer
Date of Birth *
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Age *
Your answer
Ethnicity *
Required
Parent/Caregiver Information *
Name
Your answer
Email Address
Your answer
What is the best way to contact you? *
Contact Phone *
Your answer
Alternative Phone
Your answer
An Alternative Contact Person must be provided for camp acceptance *
Name
Your answer
Address
Your answer
*
Relationship to Child
Your answer
*
Contact Phone Number
Your answer
Is this the first time your child has spent a night away from home? *
Has your child attended Edmund Rice Camp before? *
If they have attended before, when was this?
Your answer
Do you object to your child's photo being used in the public media? *
CONFIDENTIAL MEDICAL INFORMATION - All medication needs to be labelled and handed into the Camp Captains on arrival at camp. Medicines will be kept in the First Aid room and administered under supervision as required. *
Is your child currently taking medication?
Please state the name of the medication and dosage
Your answer
I give the supervisors permission to administer PARACETAMOL if needed *
Does your child have allergies to:
What special care is recommended?
Your answer
Last Tetanus immunisation was
Your answer
Can your child swim? *
How well does your child interact with their peers?
Please comment if you think we need more information about how they interact with others
Your answer
Please tick the appropriate box if your child has any of the following disabilities
If yes, please give details
Your answer
Please tick if your child suffers from any of the following
If you ticked any, could you please give us more details that might be helpful for us to care for your child.
Your answer
Please tick the appropriate box if your child needs support with any of the following
If you ticked any of the above boxes, what special care is needed?
Your answer
Are there any recent or ongoing situations at school or home which may have some impact on how your child may feel during camp?
Your answer
Medical disclaimer *
I wish my child to attend the above camp. I acknowledge that the Leaders/ Supervisors on the camp have a duty to seek medical advice for my child when necessary. I accept that the leaders will attempt to call me to gain permission, but if I am unavailable they will seek the required medical attention. Any such treatment will be provided at my expense.
I shall not hold the Supervisors, Leaders or Organisers responsible or liable for injury sustained by my child. *
This information is collected for the purposes of ensuring the well being of your child while on camp and anonymously for statistical purposes afterwards. All information given is CONFIDENTIAL in accordance with the Privacy Act 1993. *
I agree that all information that I have submitted is true and correct
Required
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