Hamerkaz Youth Adventure Camp

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HAMERKAZ YOUTH TEEN CAMP ENROLMENT FORM
22-24 January 2023

To ensure your place and early bird rate please submit enrolments no later than 08/01/2023. Late enrolments will be placed on a waiting list.
Child's Personal Details
Full Name*

First Name Last Name
Date of Birth*

Month Day Year
Gender*
School*
Grade in 2023*
Swimming Level*
Family CRN
Child CRN

Address*

Medical Details
Doctor's Name*
Phone Number*

Area Code Phone Number
Emergency Contact* (Other than Parent)

First Name Last Name
Phone Number*

Area Code Phone Number
DOES THE CHILD HAVE ANY SPECIFIC HEALTH CARE NEEDS OR CONDITIONS, INCLUDING ALLERGIES OR ANAPHYLAXIS?**

Yes No
If yes, please provide a medical management plan, which the child's medical practitioner has prepared.

The Plan should include:
- A photo of the child
- If relevant, state what triggers the medical condition, allergy or anaphylaxis
- First aid needed
- Contact details of the doctor who signed the plan
- When the Plan should be reviewed
Note: This can be emailed to [email protected]
DOES THE CHILD HAVE ANY DIETARY RESTRICTIONS?**

Yes No
(If yes, please attach relevant details.)

Note: This can be emailed to [email protected]

Medication will only be administered if it is in the original container with the original label and instructions that can be clearly read and before the expiry or use by date. Additionally, if the medication has been prescribed by a medical practitioner:
- The label must contain the child's name and
- Parents must provide any verbal or written instructions provided by the medical practitioner.
My child will/may require medicine while at the program*

Yes No
Note: Medicine must be handed in to our office daily - clearly labeled with instructions.
Parent Details
Father's Details
Father's Name*

First Name Last Name
Date of Birth*

Month Day Year
Same address as child?

Yes

Address

Address

Payment*

Credit Card

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Early Bird Rate: $300 valid until 8th January 2024 | Full Fee: $500
*

I authorise to charge the amount on my credit card not before the 08/01/2023. Cancellations made after 08.01.2023 will have a $100 charge.
Declaration

1. Accidents: in the event of ilness or injury to my child whilst attending the Teen Camp of Lamdeni School Inc and Hamerkaz Shelanu Inc: I authorise the coordinator or staff memebers in charge of my child, where it is impractible to communicate with me, to seek and obtain emergency, medical, hospital or ambulance attention or service on my behalf as may be deemed necessary.

2. Excursions/Transport: I give permission for my child to be transported and participate in all the adventerous activities and/or excursions organised as part of the teen program.

3. Privacy: I give permission for my child's photographs/videos to be used for promotional purposes.
*

I certify that all the above information is true and correct, and agree to Lamdeni & Hamerkaz Shelanu's terms and conditions as per Policy Book (copy available at our office) and Camp Form.
Should be Empty:

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HAMERKAZ YOUTH TEEN CAMP ENROLMENT FORM