2024 Children’s Application Form - Licola Wilderness Village

Lions Sponsored Camps – Children’s Application Form

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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.

Name :(Required)

Surname Given Name

Address :(Required)

Street Address City State / Province / Region ZIP / Postal Code

Age at Day 1 of 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

If so, preferred name :

PRIMARY Contact :(Required)

First Last

Address :

Same as above

Address

Street Address City State / Province / Region ZIP / Postal Code

Relationship to Child(Required)

Email(Required)

Phone (Main)(Required)

B/H

SECONDARY Contact :

First Last

Relationship to Child

Phone (Main)

B/H

Is this your child’s first Licola Sponsor camp?(Required)

Yes

If No, when was the last time your child was at Licola?

BEHAVIOURAL MANAGEMENT : (NOTE : Significant misbehaviour will result in you being requested to collect your child from camp).

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

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

Student behaviour
‘I understand that in the event of my child’s misbehaviour or behaviour that poses a danger to themselves or others during the camp, my child may be sent home. I further understand that in such circumstances I will be informed and that any costs associated with my child’s return will be my responsibility.’

Signed(Required)

How far can your child swim (without stopping)?(Required)

5 metres

10 metres

25 metres

50 metres

Unsure

Non-Swimmer

My child is not to enter the water, even though I am aware there is always a trained lifeguard on duty

DIETARY REQUIREMENTS : (NOTE : Camps are NUT FREE as per standard practice)

Vegetarian

Halal

Coeliac or Gluten Free

Dairy free

Vegan

Other

Other (please specify)

This section to be completed by the submitting school only:

DATE OF BIRTH CONFIRMED (there is no exceptions 8-11 years only on day 1 of camp)

All sections have been filled in with as much detail as possible and if necessary, current Action Plans attached

School Representative’s Name :

Date :

Signature

Full Name :(Required)

Surname Given

MEDICAL INFORMATION :

Expiry date:

Child’s reference number :

Ambulance Subscription?(Required)

Yes

If Yes, Membership Number :

Expiry date :

Private Health Cover :(Required)

Yes

If Yes, Fund Name :

Membership No :

Doctor’s Name :(Required)

Phone Number :(Required)

Doctor’s Clinic/Practice Name :(Required)

Are vaccinations UP TO DATE as per the Australian Immunisation Schedule?(Required)

Yes

Not vaccinated

MEDICAL HISTORY:

In order to provide adequate support for your child, Licola Wilderness Village needs to be aware of their needs.
Any ongoing or recurrent illness, condition or physical restriction must be disclosed to ensure appropriate safety planning can be made for your camper. Provide as much detail as possible.

** Failure to disclose may result in you being requested to collect your child from the camp. **

Bed Wetting(Required)

Yes

Hay Fever(Required)

Yes

ADD / ADHD(Required)

Yes

Hearing impairment(Required)

Yes

Specify if ADD or ADHD

Anaphylactic reaction(Required)

Yes

Food or non-food

Allergies(Required)

Yes

Allergic to what?

Asthma(Required)

Yes

Diabetes(Required)

Yes

Triggers

Seizures / Epilepsy(Required)

Yes

Heart problems(Required)

Yes

Specify if Seizures or Epilepsy

Date of last Seizures

*If YES to ANAPHYLACTIC REACTION please attach a completed “ASCIA Action Plan for Anaphylaxis” form to this application*

*If YES to ASTHMA please attach a completed “Asthma Action Plan” form to this application*

File

Drop files here or

Max. file size: 64 MB.

MEDICATIONS: **Please ensure ALL USUAL medications are brought to camp in their ORIGINAL PACKAGING**

Medications (tablets, liquid, cream, injections INCLUDING Panadol and Vitamins) MUST NOT BE in the child’s bag at camp.
ALL medication MUST be handed to the Bus Marshall – please notify them if required to be taken whilst travelling to camp.
Medications will be stored in First Aid Room and administered by First Aid Officer per written instructions. You may receive a phone call for clarification at the start of camp.

Please indicate if/which medications will be brought to camp per your child’s needs :

Panadol (Paracetamol)

Nurofen (Ibuprofen)

Sunscreen

Anti- Histamine

Asthma medication/puffers

Melatonin

Travel sickness

Other

Other (please specify)

Medication

Dose

Time Taken

AUTHORISATION(Required)

I give permission for a Lions Village Licola representative to issue prescribed medication/s per packaging instructions, as prescribed by doctor or physician. I give permission for Lions Village staff to provide sunscreen to aid in prevention of sunburn; and to check for, and treat, if necessary head lice.

In an emergency where there is insufficient time to contact Primary or Secondary Contacts; I authorise the obtaining of any medical or surgical treatment, including anaesthetic as necessary; and accept responsibility for any expense incurred in relation to such treatment.

In the event of mild illness and if deemed warranted, do you give permission for First Aid officer to administer recommended dose of:

Panadol (Paracetamol)(Required)

Yes

Nurofen (Ibuprofen)(Required)

Yes

Occasionally, Licola Wilderness Village take photos/video of campers for use in advertising campaigns on social media platforms, local media advertising, our website and promotional flyers/brochures.

Photo and Video Permission?(Required)

Yes

Photograph consent
I consent to my camper being photographed and/or visual images of my camper being taken during activities for use in Lion’s publications, website or for publicity purposes without acknowledgment and without being entitled to any remuneration or compensation.

Signed(Required)

Consent for emergency transportation
‘In the event of an emergency I consent to my child being transported in a privately owned vehicle driven by a member of the Licola camp team.’

Signed(Required)

Declare that the information provided is true and correct(Required)

I hereby declare that the information provided is true and correct at the time of completing this form.(Required)

Signature : (Signatory must be aged 18 years or over)(Required)

Comments

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