School’s Application Form - Licola Wilderness Village

Lions Sponsored Camps – School’s Application Form

This field is for validation purposes and should be left unchanged.

ALL sections of this form MUST BE COMPLETED for application to be ASSESSED. Successful applicants will be notified.

PLEASE NOTE: THIS CAMP IS NOT SUITABLE FOR CHILDREN WITH SPECIAL NEEDS

All information is confidential. Only Lions Village Licola representatives and First Aid Officers will review as required.

School Name(Required)

School Address :(Required)

Student Name(Required)

Parent/Guardian Contact Name(Required)

Parent/Guardian Email Address(Required)

Parent/Guardian Contact Phone Number(Required)

Age during Camp : (8 – 11 years only)

Age at Day 1 of Camp: (8 – 11 years only)(Required)

Date of Birth(Required)

Gender :(Required)

Boy

Girl

Alternative Gender Identity

School Representative Contact :(Required)

Position held at School(Required)

Email(Required)

Phone (Main)(Required)

Student behaviour
Does the student have any challenging behaviours? If so, please give details of the behaviour and any management strategies.

Does the student have any challenging behaviours? If so, please give details of the behaviour and any management strategies.(Required)

Signature(Required)