Catalyst Church Ipswich / What's On / A2a Youth Camp 2015

Register for youth camp by filling out the form below:

First and Last Name

Date of Birth

Gender

Youth or Youth Leader

Which Youth Group are you from?

If "OTHER" please enter Church below

Contact Info

Email Address

Phone Number

What is the best way to reach you?

Email

Phone

Address

Street Address

City

State

Post Code

Emergency Contact Details

First and Last Name

Contact Number

Relationship to Camper

Medical Details

Medical Conditions

Arthritis

Asthma

Diabetes

Epilepsy

Bleeding Condition

Kidney Disease

Heart Disease

High Blood Pressure

Other (Please state)

Do you suffer from the following drug allergies

Penicillin

Morphia

Codine

Other drug allergies (Please state)

Any other allergies inc. food or special dietary needs (Please state)

Are you self medicated or do you need medication assistance? (If yes please leave details)

Do you have any disabilities? (Please State)

Do you have any fears or phobias? (Please state)

When was your last tetanus toxin injection?

Medicare Number (Please state)

Private health fund details (If applicable)

Please indicate your swimming ability

Consent

Confirmation of Participant consent. By typing in your name in the box below you consent to participate in the camp program and acknowledge the above requirements.

Confirmation of Parental / Guardian consent. I acknowledge that use of images/video from camp (which may identify my child) may be used in promotion of A2A youth groups. By typing in your name in the box below you consent to your child's participation in the camp program and acknowledge the above requirements

How are you paying?

Payments can be made by cash or direct debit:

Bank account details BSB 633000 A/C 132187154 Reference – youth camp & surname

Camp cost is $130. Payments must be paid to Catalyst Church by the 11th September. Please contact your local church if you require a payment plan or support.

A2A Youth Camp 2016