Name*

First

Last

Gender*

Date of Birth*Rather than using the calendar you can enter the date manually using the format shown

dd/mm/yyyy

Contact Address

Address 1

Address 2

City

Province

Postal code

Country

Home Phone NumberIf you do not have a home number, please write "none"

Mobile NumberIf you do not have a moible, please write "none"

Email addressThis should be the email address of the attendee

Visa's*Please choose the most appropriate statement

Are you in good health, without any long-term ilnesses? *If YES, write YES. If NO, write NO and give further details

Have you had/Do you have any of the following health conditions?*If YES, tick those that apply, and give further details in "Other" at end of form.

Diabetes

Heart problems

Travel sickness

Kidney disease

Fainting spells

Menstrual problems

Bed-wetting

Mental health problems

Epilepsy

Hayfever

None of the above

Have you ever been hospitalised with any of the above health conditions, or any other condition not stated above?*If YES, write YES and give further details. If NO, write NO.

Have you had / Do you currently have asthma?*

Do you carry an inhaler or any other medication for your asthma?*

Have you ever been hospitalised because of your asthma*

How many times have you needed to use your blue inhaler in the past 2 weeks?*

Have you received vaccination against tetanus in the last 5 years?*

Are you allergic to any of the following?*

Penicillin

Anaesthetic

Plasters

Nuts

I am not allergic to any of the above

Do you have any other allergies (e.g. to foods, medicines etc)? *If YES, please write YES and give details. If NO, please write NO.

Do you have any special dietary requirements?*All meals will be vegetarian. If you do have dietary requirements please write YES, and give details. If NO, please write NO. Please note that we can only provide alternative food/meals based on requirement, not preference.

Are there any other medical conditions/issues that we need to be aware of? *If YES, please write YES and give further details. If NO, please write NO.

Are you currently taking any prescription medication? *If YES, please write YES and give details re: dosage, specific storage requirements etc. If NO, write NO.

Do you have any behavioural challenges that we need to be aware of?*If YES, please write YES and give details. If NO, write NO.

Do you have any disabilities that we need to be aware of?*

In the unlikely event of an emergency, please tell us who you want us to contact:*

First

Last

Relationship of above person to you:*

Home phone number*If the person to be contacted does not have a home phone number, please write "None"

Mobile number*If the person to be contacted does not have a mobile number, please write "None"

Work Tel NumberIf they have one

Your GP's name*

What is the telephone number of your GP's surgery?

GP's surgery address*

Current regulations relating to child protection issues and taking photographs of young people require that we obtain your consent for any picture taken that includes your son/daughter/child and which is used in video, on the web, or in printed publication. Please indicate your consent by selecting "yes".*If you indicate "no" your child may be excluded from some activities

The event organisers are able to provide transport to and from all off-site activities and we are required to obtain your permission beforehand. This transport will be either in a minibus/car/coach or other roadworthy vehicle, and all drivers will hold a current driving license relevant to the category of vehicle they are driving. Please indicate your consent by selecting "yes". *If you indicate "no" your child may be excluded from some activites

If you as a parent/guardian would not like your child to take part in certain activities, please give details below:

This should be read & agreed upon by both the person who will be attending the camp and the parents of that person.*Code of Conduct by Camper: This is a Christian Camp, run by the Seventh-day Adventist Church. As such, principles of Christian behaviour form the foundation of how to relate to each other and to God. The following is expected of each camper & member of staff: a) RESPECT: be respectful of yourself, others & God; b) APPEARANCE: dress appropriately for the task & occasion; c) SAFETY: listen to, and do what the leaders ask. Smoking, alcohol, drugs, knives or any other item which could be harmful to oneself or others are banned from the Camp. Possession or use of any such items could (and probably will) result in the person(s) involved being asked to leave the Camp immediately. Red Bull, Kick & other stimulant drinks are also banned. Any items like these will be confiscated. Please make sure that this is known to your children. Do you agree to abiding by these rules/guidelines?

This should be read & agreed upon by both the person who will be attending the camp and the parents of that person.*As this is a Christian camp, we have worship each morning and evening. This worship is mandatory for all campers. Please indicate that you accept this below:

This should be read & agreed upon by both the person who will be attending the camp and the parents of that person.*Mobiles may be brought to camp but should not be used in worships nor to play music out loud or to watch videos. Inappropriate use of mobiles will lead to the mobile being confiscated until the end of the Camp.

I agree to the above statement about mobile phones

I do not agree to the above statement

Commitment 1*This section should be completed by the parent / legal guardian of the person described and all statements below refer to the person who will be attending the Camp.

This application form is CORRECT as far as I know and the person described by me has permission to engage in all activities, except as noted by me. I consider them fit to participate in this youth event and acknowledge the need for obedience and responsible behaviour on their part. If any of the above circumstances / details change before the commencement of the Summer Camp, I will make it my responsibility to immediately inform the Camp Director of the change, in writing (either by post or by email).

This application form in NOT CORRECT!

Commitment 2: Medical Treatment - regular (please pick 1)*This section should be completed by the parent / legal guardian of the person described and all statements below refer to the person who will be attending the Camp.

The person to whom this form relates has been described as needing to take regular medication and they are capable of making sure they take their own medication regularly. They do not need help / supervision from the Camp medical staff.

The person to whom is form relates has been described as needing to take regular medication. They need help / supervision from the Camp medical staff and I give my agreement to this.

The person has not been described as needing any kind of medication.

Commitment 3: Medical Treatment in an Emergency.*This section should be completed by the parent / legal guardian of the person described and all statements below refer to the person who will be attending the Camp.

I agree to the person whom this form relates to receiving any urgent dental, medical or surgical treatment, including anaesthetic or blood transfusion, as considered necessary by the medical authorities present.

I do not want the person described to receive medical treatment under any circumstances.

The fee for this event is £20/€20. Please bring this with you.*ALL cheques should be made payable to "Advent Youth Society"

I agree to pay the Camp Fee

I don't agree!

Name of the parent / legal guardian who agreed to the above Commitments*Please note: ONLY the parents / legal guardians of the person who will attend the camp should fill out this form. By filling in your name below you agree that it was you who filled out the form. The Irish Mission of the Seventh-day Adventist Church cannot be held responsible for anyone who gives misleading information in this respect.

First

Last

Further Camp Information*Please indicate how you would like to receive further info about the Camp by selecting only 1 option from below:

If you have indicated that you would like to receive further information by email or through the post, please tell us what email address or postal address it should be sent to:

Anything else you have to say, or questions you would like to ask?

Date form submitted*

dd/mm/yyyy

Irish Mission Youth Ministries

2010/11 New Years Application Form - NEW