Winter Kids Camp 2017 Participant Application Form · Winter Kids Camp 2017 Participant Application Form Tuesday 4th – Friday 7th July Applications close: Friday 2 June, 2017 This

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:programs@ercvic.com

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,programs@ercvic.com

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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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