Winter Kids Camp 2017 Participant Application Form · Winter Kids Camp 2017 Participant Application...
8
Edmund Rice Camps (Victoria) Inc. – Winter Kids Camp 2017 Page 1 of 8 Winter Kids Camp 2017 Participant Application Form Tuesday 4 th – Friday 7 th July Applications close: Friday 2 June, 2017 This camp will be held at the Doxa Malmsbury Campsite. For children aged 8-11 years old. The camp program will include activities such as cooking, rock climbing, arts and crafts, bike riding and other games and activities. Successful applicants will receive an acceptance letter, a ‘what to bring’ list and details of the pick up and drop off location for the commencement and conclusion of camp. Key Information: 1. Cost of camp is $220 per participant 2. Please ensure that all forms (Personal Details, Medical, Conditions of Placement & Doxa Consent Form) are completed and signed in full before submitting. 3. All forms must include a 24hour or After Hours contact for agency referrals. 4. We’ve included a Strengths & difficulties questionnaire on Page 6. This will help us better place your child. 5. Applications with a separate letter from the referring agency will be more highly regarded. The support letter can contain • 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 Completing this form. This form can be completed electronically in Microsoft Word. Pages 4, 5, 7 & 8 must be printed and signed. IMPORTANT: Anaphylaxis Management on Edmund Rice Camps What is anaphylaxis? Anaphylaxis is a severe allergic reaction to a substance, most commonly nuts, egg, milk, wheat, soy, seafood, some insect stings and medications. It can be life threatening, but with proper management and prevention strategies in place the risks can be substantially reduced. Has your child been diagnosed with Anaphylaxis? If so, you must: 1. Make sure you let us know on the Medical Page of this form 2. Help us put together an ERC Individual Anaphylaxis Management Plan 3. Send in copies of an ASCIA action plan for your child, with an up-to-date photograph 4. Bring your Epipen® (ensure it has not expired) We take Anaphylaxis Allergies very seriously. Every Edmund Rice Camp Program is entirely nut free! Get more information: View our full Anaphylaxis Policy here: www.ercvic.com/publications.php DEECD website at www.education.vic.gov.au/anaphylaxis Anaphylaxis Australia Inc, at www.allergyfacts.org.au
Transcript of Winter Kids Camp 2017 Participant Application Form · Winter Kids Camp 2017 Participant Application...
Edmund Rice Camps (Victoria) Inc. – Winter Kids Camp 2017
Page 1 of 8
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
Edmund Rice Camps (Victoria) Inc. – Winter Kids Camp 2017
Page 2 of 8
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
Edmund Rice Camps (Victoria) Inc. – Winter Kids Camp 2017
Page 3 of 8
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
Edmund Rice Camps (Victoria) Inc. – Winter Kids Camp 2017
Page 4 of 8
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]
Edmund Rice Camps (Victoria) Inc. – Winter Kids Camp 2017
Page 5 of 8
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_____________________________________________
Edmund Rice Camps (Victoria) Inc. – Winter Kids Camp 2017
Page 6 of 8
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/
Edmund Rice Camps (Victoria) Inc. – Winter Kids Camp 2017
Page 7 of 8
Pleasefilloutthefollowingform.ThecampwillbeheldattheDoxaMalmsburyCampsite.Doxarequireallparticipantsto filloutandsignthenexttwopagesincaseofemergency.EdmundRiceCampswillgiveDoxaacopyofonlythesetwopages.
Edmund Rice Camps (Victoria) Inc. – Winter Kids Camp 2017
Page 8 of 8
