1. CAMPER’S INDEMNITY FORM
This form is to be completed by the camper if aged 18 years or over, or the camper’s parent or guardian if the
camper is under 18 years of age. One form per camper.
CAMPER’S FULL NAME : ................................................................................ DATE OF BIRTH : .......................................
PARENT / GUARDIAN’S FULL NAME : ..................................................................................................................................
ADDRESS : ...............................................................................SUBURB...........................................P/C...............................
PARENTS PHONE NUMBER : .................................... (H) ........................................(W) .........................................(MOB)
AUTHORISATION :
I, the undersigned, am willing that I / my child should participate in the camp to be held from 21st to 24th of January 2009
at QCCC Mapleton. I understand the nature of the activities at the camp may include, but may not be limited to, canoeing,
bushwalking, swimming (pool), indoor & outdoor games, sports activities, dormitory accommodation, communal eating, and
that risks may arise during these activities.
I HEREBY AUTHORISE the leader in charge of the camp or the particular activity in which I am / my child is involved, to
consent where it is impracticable to communicate with me, to my child / myself receiving such medical or surgical treatment
as the leader may deem necessary at any time during the camp. I further authorise the use of Ambulance and /or
anaesthetic by a qualified medical practitioner if in his / her judgement it is necessary. I accept responsibility for payment
of all expenses associated with such treatment.
PHOTOGRAPHS & VIDEO FOOTAGE
I give permission for Samford Valley Community Church to take and store photographs and or video footage of my child to
be used in promotion of our activities in our local community and in the church.
• Yes • No
CONFIDENTIAL MEDICAL REPORT :
The information below is requested to assist in case of any illness or accident. This information will be held in confidence.
a) Please tick if your child suffers from any of the following:
• heart condition • blackouts • asthma • sleepwalking • migraines • travel sickness
• other (please specify) ...................................................................................................................................................................
b) Are you / is your child presently taking medication? If yes, please state the name of medication and
dosage.
c) Please tick if you / your child is allergic to any of the following:
• Penicillin • Other drugs (please specify) ....................................................................................................
• Any foods (please specify) .......................................................................................................................
d) Last tetanus immunisation was : .............................................. If over 5 years, tick if a booster is to be
arranged before camp •
e) Any special care needs : ........................................................................................................................
f) Medicare No : ..............................................................
PLEASE SPECIFY ANY SPECIAL DIETARY REQUIREMENTS - eg vegetarian ....................................................................
THE FOLLOWING IS TO BE SIGNED BY A PARENT/ GUARDIAN IF CAMPER IS UNDER 18 YEARS OF AGE, OR BY
THE CAMPER IF 18 YEARS OR OVER.
 I understand that every effort will be made by the leader firstly to contact me in the event of any illness or accident.
 This is / is not the first time that my child has been away from home without the company of a parent / guardian.
 The particulars given on the confidential medical report above are correct.
 I / my child agrees to abide by the rules and guidelines of the Youth Ministry Unit and to participate in all aspects of the
camp program.
SIGNED: .......................................................................... DATE: ...............................