EmailMe Form - KUCA Campout 2017 Registration Form

*

Camper (grades 3 - 6)

Adult (18+)

Youth Leader (grade 7+)

Name *

First Last

Congregation/School/Other *

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Email Address

Date of Birth

if under 18 years of age

Grade

INDEMNITY
I hereby authorise the leader in charge of the camp, where it is impracticable to communicate with me, to arrange for my receiving such medical or surgical treatment as the leader may deem necessary at any time during KUCA Campout. I further authorise the use of ambulance and/or anaesthetic by a qualified medical practitioner if in his/her judgement it is necessary. I accept responsibility for payment of all expenses associated with such treatment. I appreciate that every care will be taken by the leaders of KUCA Camp Out and that the leaders and those connected with the camp cannot be held responsible for personal injury or loss or theft of property. *

Confirmed

Name of authorising person *

name and confirmation of parent/guardian if under 18 years of age

Emergency Contact Information

Please enter the name of the parent/guardian/individual who should be contacted in the case of an emergency.

Name *

First Last

Relationship *

Phone *

### - ### - ####

CONFIDENTIAL INFORMATION FOR FIRST AID *

Do you have any health issues that we need to be aware of?

Any Allergies?

Please provide relevant information

Please list any medications and dosage

Any Special Dietary Needs?

Medicare Number

Last Tetanus Immunisation

Family Doctor and Contact Number

PAYMENT
Cost? $40.00 covers food, camping fees, bus,, badge, diary, crafts and other equipment costs.

 I have made a Direct Debit payment to Presbytery of Tasmania BSB 017 042 Account Number 1094 99044 with "KUCA - initial and surname" included in details

Payment has been mailed/delivered (cheques payable to UC Presbytery of Tasmania, 96 Margaret Street, Launceston 7250)

BUS TRANSPORT TO AND FROM CAMP *

I DO NOT require any bus transport

I will require bus transport SATURDAY

I require bus transport SUNDAY

USE OF PHOTOS *

I give permission for photos of me/my child taken at KUCA Campout to be used for promotion, including the website.

I DO NOT give permission for photos of me/my child taken at KUCA Campout to be used for promotion, including the website.

Acknowledgement of Communion
(for those under 18 years of age) *

I acknowledge that Communion is offered during KUCA Campout

ADULT DECLARATION
(for those 18 years of age or older)

Confirmed

I acknowledge that the policy and responsibility of the Uniting Church in Australia is to provide a safe environment where children are protected from physical, spiritual, sexual or emotional abuse. I understand that as a leader at KUCA Campout I have a responsibility to do all that I can to ensure the safety of every child in my care. I declare that I have never been accused of or convicted for violence, sexual assault, any drug related offence, or any offence in relation to a minor.

WORKING WITH CHILDREN REGISTRATION
EVERYONE AGED 16+ must have a Working with Children Check

Everyone who wishes to work or volunteer in the Religious Services area must have Working with Children Registration.

The UCA Tasmanian Office has my WWC Check registration details

I have applied for my WWC Check (please note application date below)

Information or Questions or Comments

KUCA Campout is an activity of the Uniting CHurch in Australia, Presbytery of Tasmania. For further informatiob please contact the UCA Tasmanian Office 96 Margaret Street, Launceston 7250. Ph: (03) 6331 9784 Email: tas.kuca@victas.uca.org.au or tas.office@victas.uca.org.au