Relationship to Applicant :
Brett is married to Mardi and
they have four daughters (Evie,
Harriet, Olivia and Willow) and
a Cavoodle (Frankie Bones).
They love their church, St
Luke’s Miranda, where Brett has
been part of the ministry team for the last 8
years. Brett could eat burgers forever, is learning
to love netball and believes surfing is the most
exquisite art-form humankind has ever
discovered.
.
Emergency Contact Phone Numbers :
(Home)
____________________________________
(Work)
____________________________________
(Mobile) ____________________________________
Parent / Guardian Consent
I, ________________________________ being the parent or legal
guardian of the applicant mentioned over, give my consent for him / her to
attend and participate in all such activities associated with the KYCK
weekend to be held on the 29th-30th April, 2017. I understand that
personal accident insurance is the responsibility of the individual
applicant, and that while all precaution shall be taken to ensure the good
welfare and protection of the applicant, St. Clement's Anglican Church
Jannali, Katoomba Christian Convention (KCC), and their youth leaders
and staff, are released from any and all liability in the event of any
accident or misfortune that may occur to the applicant or damage or loss
to their property. In case of emergency I give permission for the Camp
Director, or the Jannali Anglican Church Youth Leaders, to seek medical
aid for the applicant (including, but not limited to hospitalisation and
surgery) and while every effort will be made to contact me prior to such
procedures, I agree to pay all such doctor's and hospital fees incurred on
behalf of the applicant.
Ross Ciano
Ross is an Australian/Italian. He is
married to the beautiful and
height appropriate Rachel. They
have two sons named Luca
Domenico and Matteo Riccardo,
whose names would sound great as Formula 1
drivers. Ross is the minister at Marrickville Rd
Church and was converted at 16 years of age at
home reading his Bible. He loves real football,
real coffee and real pasta (his mum’s lasagna).
Signed : _________________________________________
Date :
_________________________________________
Payment Total: $125 (Weekend).
Cash / Cheque (to “Jannali Anglican Parish Youth
Account”)
Credit Card (Mastercard/Visa) : 2% processing fee
Name on Card:
Card #
Exp Date:
Dan Wu
.
Signature:
.
Please return this form in a sealed envelope clearly
marked with your name to Cameron Hyslop at either
Youth Group or Church.
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Returning This Form
Dan is married to Chrissie and
they have three sons, Liam,
Archie and Harry. Dan was a
youth minister at a Cherrybrook
Anglican church in Sydney for
several years, and now teaches at
Moore College. He loves fishing, all forms of
footy, fishing, basketball, and fishing. For some
reason, he also really likes making friends with
people who own boats.
29-30 April
Brett Middleton
Name(s) : ______________________________________
Yrs 9-12
Parent / Guardian Details
Transport
The information contained in this Application Form is for
those attending KYCK 17 with Jannali Anglican Church. We
will be taking students from years 9-12 to KYCK this year.
Please read and complete the application form carefully and if
you're under 18, have it signed by a parent or guardian. If
you're over 18, you’ll still need to fill in the entire form, but
you can sign it yourself.
Once again we’ll be staying with a bunch of youth from other
churches at the Katoomba Christian Convention (KCC)
Camping Area. Bathrooms with hot showers and an electric
barbecue are provided, however we will need to bring the
rest. The Camping Area is right on site which means it’s only
a 2 minute walk to the main auditorium from your tent.
Address : __________________________________________
________________________________ Postcode : _________
Home Phone : ______________________________________
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Email : ____________________________________________
Tent
air bed or small roll up sleeping mat
sleeping bag and pillow
clothes for the weekend (it will be cold !!!)
warm jacket or jumper
pyjamas / tracksuit
walking shoes
towel & toiletries
board game or cards
camera
raincoat / umbrella
torch
Bible & pen
money for lunch (Saturday & Sunday) at Katoomba.
a sense of adventure
WEEKEND RATE
$125
Includes campsite fees, morning teas, Saturday dinner and
supper, Sunday breakfast, and the KYCK 17 registration fee
for weekend entry.
All medications should be marked with your name, when the
medication is to be taken, the nature of the illness, and the
dosage. You will need to advise Cameron Hyslop of your
medication upon arrival at the camping area.
Late applications will be received only if space is available.
Weekend registration fee quoted includes a non refundable
$20 deposit. If cancellation is made after 23rd April, a refund
is only possible with a doctor’s certificate. Cheques should be
made payable to “Jannali Anglican Parish Youth Account”.
Mobile Phone : ______________________________________
What to Bring
Medications
Applications close on Sunday 23rd April, 2017.
Application & Indemnity
Name : ____________________________________________
Cost
Numbers are limited and time is short. Telephone enquiries
are welcome on 0417 415 027, however we are unable to
accept telephone bookings.
29th-30th April, 2017
Sex :
M/F
Date of Birth : _____________________
School :
Year : ____
Health Information
Please answer all questions.
Attach a separate page if you require more space.
Is the applicant allergic to penicillin, or any other medication, drug,
insect, plant, food, environmental condition etc ?
Yes / No
If “Yes”, give details (include treatment) : ___________________
__________________________________________________
__________________________________________________
Is the applicant on a special diet ?
Yes / No
If “Yes”, give details : __________________________________
__________________________________________________
__________________________________________________
Is there any other personal information that the Camp Director or
Youth Leaders would need to be aware of (eg asthma, diabetes,
epilepsy, phobias, headaches, sleeping or behavioural difficulties,
heart problems, medications, disabilities, etc.) ?
Yes / No
If “Yes”, give details (include treatment) : ___________________
Tent Setup
__________________________________________________
Tents will be taken up earlier on Friday 28th April so they can
be set up before we arrive. Please have your tents delivered to
the church office by 5pm on Thursday 27th April.
__________________________________________________
Emergency Contact
Date of last Tetanus Booster : ___________________________
Emergency contact can be made during KYCK 17 by phoning
Cameron Hyslop on 0417 415 027. This phone is for incoming
calls only.
Card Ref Number : ________ Exp. Date : _________________
__________________________________________________
__________________________________________________
Applicant's Medicare No. : ______________________________
Health Ins Co : ________________ Number. : ______________
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KYCK 17 is all about STANDING FOR THE KING. There
will be three speakers this year who will each give two talks
taking us through the Old Testament book of Daniel. It’s all
about recognising the true king and the importance of
standing for him in a world that seeks to worship false kings.
All transport is in leader’s cars (No P plates). We’ll meet at
Jannali Anglican Church (83 Wattle Rd, Jannali) at 6:30am on
Saturday 29th April and drive to Katoomba. We’ll arrive in
time to register and enter the KCC auditorium for the first
session at 9am. On Sunday 30th April we'll return to the
church at approximately 3pm.
Family Doctor : __________________ Phone :______________