Antiochian Village Student Enrolment Form

*Disclaimer: this form must be completed by parents or guardians for children under age of 18 and should be given to Camp Organizer prior to staying in the village

Participant Details

Name

Birthdate

Phone

Parent / Guardian Details

Name

Relationship to participant

This address will receive a confirmation email

Phone

Address

Additional Emergency Contact

In case of emergency please provide the name of a person to contact first if The Antiochian Village is unable to contact Parent/Guardian listed above

Name

Relationship to participant

Phone

Address

Special Requirements

Are there any special social/medical circumstances (for example: Asthma, Epilepsy, legal family arrangements) about the student seeking to stay at The Antiochian Village? Yes No

If yes, please provide a brief description of the circumstances:

Does the student have any special or support needs, including any disability? Yes No

If yes, please specify:

Please note: if any disability support is specified, the supervision of parents is required whilst the student attends The Antiochian Village (that is, at least one parent is required to attend with the student)

Student Medical Details and Health Conditions

This is important information for your child’s safe participation at The Antiochian Village. It is essential that you inform The Antiochian Village if your child has any medical conditions. This must include any known allergies, other medical conditions or changes to an existing condition. This will assist The Antiochian Village to support the safety and wellbeing of your child and allow planning to occur to determine the best way to meet the individual health and support needs of your child.

Does your child take any medication?

Yes No

If yes send the medication with your child and please provide the instructions to administer the medication:

ALLERGIES - THESE CAN INCLUDE ALLERGIES TO INSECT STINGS, DRUGS, LATEX, FOOD (E.G. NUTS EGG PEANUTS) OR OTHER.

If your child has an allergy, please specify below:

For this allergy, answer the 5 questions that follow

Has the doctor diagnosed this allergy? Yes No

Is this a severe allergy (anaphylaxis)? Anaphylaxis is a severe, potentially life-threatening allergic reaction Yes No

Does your child have an ASCIA Action Plan for Allergic Reactions? Yes No

If yes, is the plan been sent to the organiser? It is important that any updated plan is provided to the staff/volunteers organising the camp. Yes No

Please list any other medications prescribed for this allergy

If an Epipen is required, the student must bring their own

Consent

Please note that this form has been modelled on the Department of Education Enrolment form that schools use.

I give permission to my child attending the Antiochian Village Church Camp.

I consent to The Antiochian Village Staff and Volunteers to contact the relevant health professionals when necessary for the care of my child (e.g. emergency). I consent to the health professional(s) treating any medical or health condition identified in this application, to provide The Antiochian Village Staff and Volunteers with information about any condition that has been identified in this application. This may include any other aspects of the student’s health that may impact on the condition or on the health and safety of this student or other students at or staff at The Antiochian Village.

I understand that whilst great care will be taken, unforeseen negative events can occur. I understand the risks involved in sending my child to The Antiochian Village.

The Antiochian Village is owned by The Antiochian Orthodox Church Property Trust(AOCPT), and I waive, release and discharge AOCPT, its members, volunteers and participants from all liability for or by reason of any damage, loss or injury to my child, myself or my property, which has or may be sustained by reason of my child’s attendance and participation in any activity at the Antiochian Village, notwithstanding that any damage, loss or injury may have been caused solely or partly by AOCPT, its members, volunteers and/or participants.

I consent to the administration of first aid and the use of emergency medical staff should the need arise including any cost incurred through medical of my child (Ex ambulance, …. )

I understand that it is my responsibility to provide the medication required by my child with the necessary instructions.

Declaration of accuracy and signature

I declare that the information provided in this application is, to the best of my knowledge and belief, accurate and complete. I have read and understand the information in this application including the consent.

Full name of parent/guardian:

Antiochian Village Student Enrolment Form

Description

Please Fix the Following