Edmund Rice Camps NSW
Application Form
DATE OF REFERRAL:
_______/_________/_______
PARTICIPANT DETAILS:
Child’s Name: _________________________________________________ Gender: Male / Female (circle)
Address: ______________________________________Suburb:___________________Postcode:________
Date of Birth:_____ / _____ / _____ School Currently Attending___________________________________
What is the main language spoken at home?___________________________________________________
Does the child identify as Aboriginal or Torres Strait Islander? (specify)______________________________
PARENT / GUARDIAN DETAILS:
Parent / guardian’s name:__________________________________________________________________
Relationship to child:________________________________________ Date of Birth:_____ / _____ / _____
Home Address:___________________________________________________________________________
Home Phone:_____________________ Work Phone: ___________Mobile Phone: ___________________
Name of Next of Kin: _________________________________Relationship to child:__________________
Home Phone:_________________ Work Phone: _______________Mobile Phone:___________________
REFERRAL AGENCY DETAILS (if applicable):
Name of referring Agency:__________________________________________________________________
Name of Staff Member: _____________________________________ Position: ______________________
Agency Postal Address:____________________________________________________________________
Suburb:______________________________________________ Post Code: _________________________
Agency Phone: __________________________________ After Hours Phone: ________________________
Email: __________________________________________________________________________________
Completed other E.R. Camp? YES / NO (circle) If so, when? _______________________________________
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Medical, Privacy and Permission Form
This report is compiled to assist Edmund Rice Camps staff and volunteers in the eventuality of any illness or accident
with your child on camp. This information is held by staff on camp. Please be as specific as possible.
1. Child’s Full Name: ______________________________________________________________
Medicare No: _____________________________________ Expiry Date: _________________________
Private Health Cover: YES / NO (circle)
Name of fund: ____________________________________ Membership No: _____________________
Child’s Doctor Name: ______________________________ Doctor’s Phone No: ____________________
Date of last tetanus shot? __________________________
2. Dietary Requirements of the child: (Eg Vegetarian, Vegan, Lactose Free)______________________
_________________________________________________________________________________
_________________________________________________________________________________
3. Please tick the appropriate box if your child has allergies to any of the following:
□ Penicillin
□ Specific Foods
□ Food Additives
□ Other
Does your child require an EpiPen (circle)? YES / NO
If yes, an anaphylaxix medical management action plan signed by the Registered Medical Practitioner giving written
consent to use the auto-injection device in line with this action plan must be provided with this application. Edmund
Rice Camps staff/volunteers must be provided with a compete auto-injection device on arrival at camp.
If an EpiPen is not required, please provide details on how to care for this allergy: ______________
_________________________________________________________________________________
4. Please tick the appropriate box if your child suffers from the following:
□ Bed Wetting
□ Seizures
□ Dizzy Spells
□ Asthma
□ Travel Sickness
□ Sleepwalking
□ Hearing Loss
□ Hay fever
□ Headaches
□ Diabetes
□ Heart Condition
□ Fears/Phobias
□ Vision Impairment
□ Soiling
□ Blackouts
□ Other
If Yes, please give details:_______________________________________________________________
5. Does your child have any chronic illness, medical condition, or physical restriction? YES / NO
____________________________________________________________________________________
____________________________________________________________________________________
6. Please tick the box which best describes your child’s ability to swim:
□ Excellent
□ Good
□ Poor
□ Non Swimmer
Further Comments: ____________________________________________________________________
7. Is this your child’s first trip away from home without you? YES / NO
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Medical, Privacy and Permission Form (page 2)
8. Please tick the appropriate box if you child has been diagnosed with any of the following:
□ Autism
□ Aspergers Syndrome
□ ADHD
□ Intellectual Disability
□ Physical Disability
□ ODD
□ Mental Health Condition
□ Tourette ’s syndrome
□ Other
If Yes, please provide a Behaviour Management Plan and further details:_________________________
__________________________________________________________________________________
9. Please tick the appropriate box if your child needs assistance with any of the following:
□ Bedtime
□ Toileting
□ Personal Hygiene
□ Meal Times
□ Showering
□ Other
If Yes, please give details:_______________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
10. All prescribed medication is the be provided in a pharmacy issues Blister Pack, Webster Pack, or
Dossette Box, that is clearly labeled. If your child is on medication, please list below:
Medication Name
Dosage
Before
B/Fast
B/Fast
Other
times
Lunch
Other
times
Dinner
Other
times
Bedtime
Further Comments and Side Effects: _________________________________________________________
_______________________________________________________________________________________
PARENT'S/GUARDIAN'S STATEMENT
I____________________________________(Parents/Guardians Name), being the parent/guardian
of ____________________________________ (Campers Name) give permission for him/her to engage and
participate in this Edmund Rice Camp for the dates mentioned, as well as the designated Edmund Rice
Camp Picnic Day. I acknowledge that the supervisors will take every care at the camp and have undergone
special training in caring for children. I accept that the supervising adults (Volunteers) will not incur liability
for any accidental injury sustained by my child.
I allow Edmund Rice Camps NSW to use photographs or videos, taped whilst in their care, for promotional
purposes, including publications in the media, advertising and to be held in ERCNSW archives.
I authorise Edmund Rice Supervisors in the event of any accident or illness and where it is not possible or
reasonable to obtain my consent at that time to engage any medical practitioner or hospital facilities and
in this event I agree to pay all such doctor, nurse or hospital expenses. I expect that I will be informed as
soon as possible.
PARENT'S/ GUARDIAN'S SIGNATURE ______________________________
DATE: ________________
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Participant Service Profile
Name: _________________________________________________________________________________
** TO BE COMPLETED BY THE REFERRER **
Listed below are questions focusing on the needs on the participant attending a camp.
By taking the time to fill this out accurately, you will help in the application process,
and if this child is successful in obtaining a position on camp, this will enable us to
provide the best possible services to the child.
1. How will attending an Edmund Rice Camp benefit this participant?
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
2. For what reasons what you referred this participant to Edmund Rice Camps?
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
3. Are there recent or ongoing situations at home or school which may have some impact on the child
whilst on camp?
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
4. Does the child have any behavior concerns or issues that may be apparent on camp? How are these
best managed?
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
5. What are the child’s interests, hobbies, strengths, talents, and likes?
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
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Edmund Rice Camps
CONDITIONS OF PLACEMENT
Please read the following information relating to camps conducted by Edmund Rice Camps (ERC). A signed
copy, signifying acceptance of these conditions and a belief on the case worker’s (or carer’s) part that the
child seeking placement is suited to ERC programs, must accompany each application for placement on an
Edmund Rice Camp.
1. Edmund Rice Camps are coordinated by 1 staff member and run by volunteers, principally aged 16 to 30.
All Volunteers are trained and screened by Edmund Rice Camps NSW, but do not hold specific
qualifications to this field.
2. All information which may affect the behaviour of the child on the camp, including their interaction with
Volunteers and other participants within the age range of the camp, must be forwarded with the
application.
3. Transport of the child to and from the designated pick up and drop off point, at the commencement and
conclusion of the camp, is not the responsibility of Edmund Rice Camps. Arrangements can be made with
the office if needed.
4. The caseworker or carer’s contact phone number, both during business hours and after hours, is to be
provided with the application.
5. Should a child need to leave camp, due to illness or inappropriate behaviour, it is the agency/carer’s
responsibility to provide transport.
6. The child is experiencing disadvantage or marginalisation through financial, social, or emotional
situations.
7. Edmund Rice Camps NSW reserves the right to accept or reject any application based on the best
possible match between applicants and the skills of the Volunteers for a particular camp.
8. It is the agency’s / care’s responsibility to ensure that the child has appropriate clothing and equipment
for the camp. ERC must be notified in advance if extra clothing and/or equipment is needed.
I have read and understood the above conditions under which Edmund Rice Camps NSW conduct
programs. Based on this information I believe the child I am referring for placement on this camp is
suited to the conditions under which the camp is to operate.
DATE:
PARTICIPANTS NAME:
_____________________________
____________________________________
CASE WORKER / CARER NAME: ___________________________________
SIGNATURE:
__________________________________________
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Winter Camps 2014
Both Winter Camps for 2014 will be run from ‘Winbourne’, 1315 Mulgoa Road, Mulgoa.
Families have 2 transport options.
1. Children can be dropped off and picked up directly from Winbourne on the first and final day of
camp.
2. Children can be picked up by Edmund Rice Camps staff and volunteers at the footbridge at Mt
Druitt Train Station (the shopping centre side). The meeting time for the first day of camp is 10am,
and the pickup time for the final day of camp is 3pm.
Please tick which camp you would like to attend:
JUNIOR CAMP Week 1:
□
□
Monday 30th June – Friday 4th July
Mt Druitt
□
Directly to camp
SENIOR CAMP Week 2:
□
□
Monday 7th July- Friday 11th July
Mt Druitt
□
Directly to camp
PLEASE NOTE: This is an application for a position on camp, it does not guarantee a place and you will be
notified if one is appointed to you.
Please return this information to:
Executive Officer, Edmund Rice Camps, Anneke Pike
[email protected]
PO BOX 2219, Homebush West, NSW 2140
Ph: 02 8762 4234
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