Fresh Camp

Camp Medical & Consent Form

We require these details for your registration to be completed and in case of an emergency or medical issue. At the end, you will be given option to complete it for another person in your household. Those under 18, the form is to be filled out by your parent/caregiver.

Camp Attendee

Youth First Name *

Youth Last Name *

Youth Date of Birth *

Youth School Year *

Gender

Which church campus are you from? *

Eastgate Pakūranga

Eastgate Te Kauwhata

Home Address

Home Suburb

Emergency/Caregiver Contact

Emergency Contact Name *

Emergency Contact Mobile *

Email Address

Second Contact Name

Second Contact Mobile

Medical & Health information

Dietary Requirements (you can select more than one)

Does your child/youth suffer any of the following:

Does your child have any allergies to the following:

Please give further information:

Does your child carry an epipen?

What was the date of your child's last tetanus injection? (approx. date acceptable)

Do you give permission for your child to be given a tetanus injection if a medical professional recommends it?

Yes

My child is taking medication *

Yes

Medication name *

Medication dosage

Time(s) to be taken

My child can manage this medication themselves

Yes

No - please remind them

Please note that all medication for young people will be held by a designated leader with a medication log. This leader will discreetly remind your young person to take their medication if required.

Does your child have any further medical concerns that could influence their participation in any activities or have other special instructions that leaders should know about?

Yes

Other Notes/Comments

Important Permissions

Medical Liability Release

I agree that my child should take part in such activities and such necessary duties as may be required by leadership. I understand that Eastgate Christian Centre will not accept responsibility for loss or damage of personal property (check own household policy).

I authorise Eastgate Christian Centre staff to administer ‘over-the-counter’ medication as required and within the manufacturer‘s guidelines. I authorise the obtaining, on my behalf, any medical assistance, if, in the opinion of the staff, such treatment is necessary, and agree to meet any costs incurred.

I release Eastgate Christian Centre, its agents, employees and volunteer assistants from any liability whatsoever arising out of an injury, damage or loss which may be sustained by my child during the course of his/her involvement with the Eastgate Christian Centre Youth programme.

PLEASE NOTE: The staff of Eastgate Christian Centre have taken all practical steps to identify hazards and minimise risk on this activity. All adults involved have been informed and prepared for their supervisory role.

All reasonable steps have been taken to manage this activity safely and responsibly.

By ticking yes, I (the parent/guardian) agree to the above medical liability release.

Medical Liability Release *

Yes

Transportation Release

Any vehicle used for transportation of young people will have a current WOF and registration. Any person operating a vehicle used for transportation of young people holds a Full License and has been Police Vetted.

I give permission for my child to be transported by private or hired vehicle to and from Camp *

Yes

Participant and Parent/Guardian Agreement

Eastgate Christian Centre will keep all information private and confidential. Team members may use photographs and videos from Eastgate activities on our printed materials and online. Please contact us in writing if you prefer your child to not appear in print or online.

I agree that to the best of my knowledge, all of the details given are true and correct.

I acknowledge this camp will have Christian elements. I agree to follow all instructions from those in charge of this camp and understand that no smoking, alcohol or illegal drugs are permitted. Failure to follow these instructions may result in instant removal from camp at own expense.

I release Eastgate Christian Centre from any responsibility from any accidental physical injury or illness while on the trip.

By ticking yes below, I (the parent/caregiver) agree to the above participant and parent/caregiver agreement.

Guardian agreement

Yes

Privacy

INFO: Eastgate collects your information for communication and administration. We do not sell or share it and keep it confidential to staff. You can request access to or deletion of your information at any time. *

IMAGES: Eastgate uses event photos/videos for promotion, which may include your face. By giving permission, you waive rights to royalties. If you withhold permission, we respect your choice but cannot ensure images of your back/body wont appear. *

Fresh Camp Attendee 0