Winter Kids Camp 2017 Participant Application Form · Winter Kids Camp 2017 Participant Application...
Transcript of Winter Kids Camp 2017 Participant Application Form · Winter Kids Camp 2017 Participant Application...
Edmund Rice Camps (Victoria) Inc. – Winter Kids Camp 2017
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WinterKidsCamp2017
ParticipantApplicationFormTuesday4th–Friday7thJuly
Applicationsclose:Friday2June,2017
ThiscampwillbeheldattheDoxaMalmsburyCampsite.Forchildrenaged8-11yearsold.Thecampprogramwillincludeactivitiessuchascooking,rockclimbing,artsandcrafts,bikeridingandothergamesandactivities.
Successfulapplicantswillreceiveanacceptanceletter,a‘whattobring’listanddetailsofthepickupanddropofflocationforthecommencementandconclusionofcamp.KeyInformation:1. Costofcampis$220perparticipant2. Pleaseensurethatallforms(PersonalDetails,Medical,ConditionsofPlacement&DoxaConsent
Form)arecompletedandsignedinfullbeforesubmitting.3. Allformsmustincludea24hourorAfterHourscontactforagencyreferrals.4. We’veincludedaStrengths&difficultiesquestionnaireonPage6.Thiswillhelpusbetterplace
yourchild.5. Applicationswithaseparateletterfromthereferringagencywillbemorehighlyregarded.The
supportlettercancontain• reasons for referral, • any goals for the participant in attending the camp, • other relevant information to be able to support the participant during this placement if
successful Completingthisform.ThisformcanbecompletedelectronicallyinMicrosoftWord.Pages4,5,7&8mustbeprintedandsigned.IMPORTANT:AnaphylaxisManagementonEdmundRiceCampsWhatisanaphylaxis?Anaphylaxisisasevereallergicreactiontoasubstance,mostcommonlynuts,egg,milk,wheat,soy,seafood,someinsectstingsandmedications.Itcanbelifethreatening,butwithpropermanagementandpreventionstrategiesinplacetheriskscanbesubstantiallyreduced.HasyourchildbeendiagnosedwithAnaphylaxis?Ifso,youmust:
1. MakesureyouletusknowontheMedicalPageofthisform2. HelpusputtogetheranERCIndividualAnaphylaxisManagementPlan3. SendincopiesofanASCIAactionplanforyourchild,withanup-to-date
photograph4. BringyourEpipen®(ensureithasnotexpired)
WetakeAnaphylaxisAllergiesveryseriously.EveryEdmundRiceCampProgramisentirelynutfree!Getmoreinformation:
ViewourfullAnaphylaxisPolicyhere:www.ercvic.com/publications.phpDEECDwebsiteatwww.education.vic.gov.au/anaphylaxisAnaphylaxisAustraliaInc,atwww.allergyfacts.org.au
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PersonalDetails
Participantdetails:Participant’sname:
Gender
Address:
Suburb:
PostCode:
DateofBirth:
AgeonCamp:
Parent/GuardianDetails:
Parent/Guardian’sname:
Relationshiptoparticipant:
Address:
Suburb:
Post Code:
HomePhone:
WorkPhone:
MobilePhone:
NameofNextofKin
Relationshiptoparticipant:
HomePhone:
WorkPhone:
MobilePhone:
Preferencefordropoff&pickup:Pleasecircleoneoneachline
Dropoff(startofcamp) AlbertParkLake(AughtieDrive) BrimbankPark,KeilorEastPickup(endofcamp) AlbertParkLake(AughtieDrive) BrimbankPark,KeilorEast
AgencyDetails:NameofRefferringAgency:
ContactPerson:
Address:
Suburb:
PostCode:
AgencyPhone:
AfterHoursContact:
Afterhoursphone:
Email:
HasthechildcompletedotherE.R.Camp?Ifso,when?
PleaseNote:IfanafterhoursphonenumberisnotavailablefromthereferringagencypleasecallAdrianattheERCoffice
beforelodgingthisformtodiscussotherarrangements,otherwiseyourapplicationwillnotbeaccepted.
IfyouhaveanyquestionspleasecontactAdrianScerriattheERCofficeon–Phone:0383590143Mobile:0408454156Email:[email protected]
Alternativelyyoucanvisitourwebsitewww.ercvic.comOfficeUseOnlyDatabaseID Receiveddate Receivedmethod
Status Formenteredby Formentereddate
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Medical,PrivacyandPermissionThisreportiscompiledtoassistEdmundRiceCampsstaffandvolunteersintheeventualityofanyillnessor
accidentoncampandwillbeheldoncamp.Pleasebeasspecificaspossibleinyourresponses.
CONFIDENTIAL
1.Participant’sName:
MedicareNo:
Expiry:
HealthCareCardNo:
Expiry:
Doctor’sName:
Doctor’sPhoneNo:
DateoflastTetanusShot:
AmbulanceCover PrivateHealthInsurance
2.Dietaryrequirements:(E.G.vegetarian,Vegan,GlutenorFructoseFree)
3.Doesyourchildhaveanyallergies?(ie.Penicillin,SpecificFoods,FoodAdditives,Drugsetc.)
4a.HasyourchildbeendiagnosedwithAnaphlaxis?
b.DoesyourchildhaveanEpiPen(Pleasecircle)? Ifyou’vebeendiagnosedwithAnaphylaxis:
qHelpusputtogetheranERCIndividualAnaphylaxisManagementPlanqSendincopiesofanASCIAactionplanforyourchild,withanup-to-datephotographqBringyourEpipen®(ensureithasnotexpired)
5.HasyourchildbeendiagnosedwithAsthma(pleasecircle)?NoneIfyourchild’sasthmaisdescribedasbeingsevere,anasthmamanagementplansignedbyaRegisteredMedicalPractitionermustbeprovidedwiththisapplicationalongwithdosageamountsandprescribedmedications.AsthmaManagementPlanAttached
6.Pleaseticktheappropriateboxifyourchildsuffersfromthefollowing:BedWetting Seizures DizzySpells SoilingTravelSickness Sleepwalking HearingLoss HayFeverHeadaches Diabetes HeartCondition Fears/PhobiasSightLoss BlackOuts Other
Details:
7.Doesyourchildhaveanychronicillness,medicalconditionorphysicalrestriction? Ifyes,pleasegivedetails:
8.Pleaseticktheappropriateboxifyourchildhasanyofthefollowingdisabilities:Autism AspergersSyndrome ADHD/ADDIntellectualDisability PhysicalDisability ODDMentalHealth/Illness AcquiredBrainInjury Other
IfYes,pleaseprovideaBehaviourManagementPlanorfurtherdetailsofwhatassiststhem:
9.Pleaseticktheappropriateboxifyourchildneedshelpwithanyofthebelow:Bedtime Toileting Hygiene MealTimes Showering Other
Details:
10.Pleasetickwhichboxbestdescribesyourchild’sabilitytoswim:SelectFurthercomments:
11. All prescribed medication is to be stored in a Blister Pack or Dosette Box that is clearly labeled.Ifyourchildisonmedicationpleaselistbelow:MedicationName Frequency & Time
ofdayDosage Comments
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12.Arethereanyrecentorongoingsituationsatschoolorhomewhichmayhavesomeimpactonyourchildduringcamp?
13.Whatdoesyourchildlikedoing,whataretheirinterests?
14.Doesyourchildpresentwithanychallengingbehaviours?Ifso,what’sthebestwaytorespondtothese?
DISCLAIMERSubjecttoanylawtothecontrary,andtothemaximumextentpermittedbylaw,EdmundRiceCampsInc.Victoriaanditsofficers,employeesandagentsdisclaimallliabilityforanylossordamage(whetherforeseeableornot)sufferedbyanypersonparticipatingonacampofferedbyEdmundRiceCampsInc.Victoriawhetherthelossordamagearisesinconnectionwithanynegligence,defaultor lackof careon thepartofEdmundRiceCamps Inc.Victoriaor anyof itsrepresentativesoranyothercause.PRIVACYDoesEdmundRiceCampsInc.Victoriahaveyourpermissiontoreproduceanyphotographs,videofootageand/oraudiorecordingstakenonthecampofyourchild,inanyofourpublicationsandwebsite,ontheunderstandingthatnonamesaretobeusedwithoutyourauthorisation? Photographs,Audio&Video Yes No
PERMISSIONTOATTENDANDMEDICALAUTHORITYI_______________________________________beingparent/guardianof_______________________________________dogivepermissionforhim/hertoengageandparticipateinthisEdmundRiceCampandtheactivitiesoffered.Ifurtherauthorisethatanydulyauthorised agents of EdmundRice Camps Inc in the event of any accident or illness andwhere it is not possible orreasonabletoobtainmyconsentatthetimetoengageanymedicalpractitionerorhospitalfacilitiesoraccommodationandinthiseventIagreetopayallsuchambulance,doctor,nurseorhospitalexpenses.IhavereadandIaccepttheaboveconditionsanddisclaimerrelatingtoparticipationinEdmundRiceCampsInc.VictoriaprogramsandIgivemypermissionformyson/daughtertotakepartinthem.Signed_______________________________________________________________________________________Date_______________________________(Parent/Guardian)
INCOMPLETEFORMSWILLNOTBEACCEPTEDWEAREUNABLETOACCEPTFAXEDFORMS
Postformsto:EdmundRiceCamps,7AmberleyWay,LowerPlentyVIC3093Emailformsto:AdrianScerri,[email protected]
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CONDITIONSOFPLACEMENT
PleasereadthefollowinginformationrelatingtocampsconductedbyEdmundRiceCampsVictoriaInc.Asignedcopy, signifying acceptance of these conditions and a belief on the Agency’s part that the participant(s) seekingplacementissuitedtoERCprograms,mustaccompanyeachapplicationforplacementonanEdmundRiceCamp.
1.EdmundRiceCampsarestaffedentirelybyvolunteers,principallyaged17to30.Whilevolunteerswithsomeprofessionalqualificationsholdexecutiveleadershiprolesoneachcamp,themajorityofleadersdonotholdsuchqualifications.
2. All information thatmay affect the behaviour of the participant(s) on the camp, including their interactionwithleadersandotherparticipantswithintheagerangeofthecamp,mustbeforwardedwiththeapplication.
3.Transportoftheparticipant(s)toandfromthedesignatedpickupanddropoffpoint,atthecommencementandconclusionofthecamp,isnottheresponsibilityofEdmundRiceCamps.
AChildProtectionMatter isanyinformationrelatingtoachildunder18yearsofagepertainingtoanypastorcurrent,actualorsuspectedconcernforthatchild'ssafety,welfareorhealth.
4. If aChildProtectionMatter ariseson camp,EdmundRiceCampswillmake contactwith theAgencywith thedetails.ERC incollaborationwith theAgencywill thendevelopaplan tonotifyandsupport thechild and family, and to contact theDepartment of Human Serviceswhere appropriate. The AgencywillnotifyERCpriortothereleaseofthisinformationtothefamilyorcarerduringthecamp.
5.TheAgencywillnotifyEdmundRiceCampsofanyrelevantandongoingChildProtectionMatteraboutthechildpriortothebeginningofthecamp.Thisinformationwillbekeptinconfidence.
6.TheAgency’scontactphonenumber,bothduringbusinesshoursandafterhours,istobeprovidedwiththeapplication.ThisisimportantinthecasethataChildProtection,healthorbehaviouralissuearises.
7.Shouldaparticipant(s)needtobesenthomefromacamp,duetoillnessorinappropriatebehaviour,itistheresponsibilityoftheAgencytoprovidetransport.
8. The participant(s) seeking placement must fit the criteria of being either socially or economicallydisadvantaged.
9. Edmund Rice Camps Inc. reserves the right to accept or reject any application based on the best possiblematchbetweenapplicantsandtheskillsofthevolunteersonaparticularcamp.
10.ItistheresponsibilityoftheAgencytoensurethattheparticipanthasappropriateclothingandequipmentforthecamp.Ifextraclothingand/orequipmentareneeded,pleasecontacttheERCofficeforalternatives.
11.Theparticipant(s)maybe invited to takepart inanoptionalevaluationof thecamp,all responseswillbeconfidential,theresponseswillbecollatedalongwithresponsesfromagenciesandvolunteersthende-identifiedtoevaluatetheentirecampanditsprocesses.EdmundRiceCampsInc.valuesallfeedbackreceived.ThepurposeoftheevaluationistoexpandontheresourcesandprogramsdeliveredbyEdmundRiceCampsInc.infuture.
12.ItistheresponsibilityoftheAgencytopaytheparticipantfeebeforecamp.ERCacknowledgesthatAgenciesmay seeka contributionof this fee from theparticipant’s family, however it remains the responsibilityof theAgencytoensurethatthisfeeispaid.
13.PriortocampERCincurscostsincludingcatering,accommodationandequipment.ERCisthereforeunabletorefundtheparticipantfeeintheeventthattheparticipantcannolongerattendtheprogram.Asanot-for-profit,ERCsubsidisesthefeesthroughfundraising,in-kinddonationsandsignificantvolunteersupport.
I have read and understood the above conditions under which Edmund Rice Camps Inc. conductprogramsinVictoria.BasedonthisinformationIbelievethechildIamreferringforplacementonthiscampissuitedtotheconditionsunderwhichthecampistooperate.
Signed_____________________________________________ Signed_____________________________________________
(AgencyWorker) (Parent/Guardian)
Name______________________________________________ Name_____________________________________________
Date______________________________________________ Date_____________________________________________
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StrengthsanddifficultiesquestionnaireTohelpusplaceyourchildinagroupandtoensurethecamphasabalanceofchallengingandmilderbehaviours,weinviteyoutofillouttheStrengthsandDifficultiesQuestionnaire.Wewillusetheresultsofthisquestionnairegettoknowyouchildabitbetterandtoensurethattheyhavethesupportthattheyneedonthecamp.Thesurveytakesjust3-5minutestofillout.Ifyou’dprefernottofillitout,youcanskipthisbutwewillprioritiseapplicationsthathavefilledoutthesurvey.Thequestionnaireisbestfilledoutbythechild’sprimarycarer.Foreachitem,pleasemarktheboxforNotTrue,SomewhatTrueorCertainlyTrue.Itwouldhelpusifyouansweredallitemsasbestyoucanevenifyouarenotabsolutelycertain.Pleasegiveyouranswersonthebasisofthechild'sbehaviouroverthelastsixmonths.
Nottrue Somewhattrue
Certainlytrue
Considerateofotherpeople’sfeelings
Restless,overactive,cannotstaystillforlong
Oftencomplainsofheadaches,stomach-achesorsickness
Oftenlosestemper
Rathersolitary,preferstoplayalone
Generallywellbehaved,usuallydoeswhatadultsrequest
Manyworriesoroftenseemsworried
Constantlyfidgetingorsquirming
Hasatleastonegoodfriend
Oftenfightswithotherchildrenorbulliesthem
Oftenunhappy,depressedortearful
Generallylikedbyotherchildren
Easilydistracted,concentrationwanders
Nervousorclingyinnewsituations,easilylosesconfidence
Oftenliesorcheats
Pickedonorbulliedbyotherchildren
Thinksthingsoutbeforeacting
Stealsfromhome,schoolorelsewhere
Manyfears,easilyscared
Goodattentionspan,seeschoresorhomeworkthroughtotheend Note:thisisthefirsttimewe’reusingthisquestionnaire.Ifyou’vegotanyfeedbackpleaseletmeknow.Moreinformationonthisstandardizedquestionnaireavailablefrom:http://www.sdqinfo.com/
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Pleasefilloutthefollowingform.ThecampwillbeheldattheDoxaMalmsburyCampsite.Doxarequireallparticipantsto filloutandsignthenexttwopagesincaseofemergency.EdmundRiceCampswillgiveDoxaacopyofonlythesetwopages.
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