Younglife.org.au

Activity Medical & Indemnity Form – Camp Form
(Campers / U18’s)
Young Life Area:
This report is intended to assist YL leaders in case of any special care needed for your son/daughter. Al information is held in confidence.
Personal Information: to be completed by the parent/guardian.
Your name (Parent /Guardian with whom the attendee primarily resides):
Secondary Parent’s/Guardian’s Name (if other than resident):
Medical Information
Name & Phone Number of Family Doctor: Allergies
What occurs if contact with allergy occurs (eg. itchy, rash, headache, anaphylaxis): Please tick any relevant columns if the attendee or any family members have had any of the fol owing. Please provide additional details (eg. severity, normal treatment, behavioural plans) if necessary. If your child has a specific behavioural management or treatment plan, please attach separately. Medical Condition ADHD (Attention Deficit-Hyperactivity Disorder) Any other conditions (medical, mental health or eg. pregnancy) or any further information we should know about:
Medication:
Self-administers:
Name of medication:
Reason for medication:
Time(s) taken:

Young Life will have only the following non-prescription
Medication
medication during camp: Paracetamol (Panadol), Ibuprofen Paracetamol
(Nurofen) and Antihistamines. Should your child ask for either medication, do you give permission for non- prescription medication to be given to your child? Other information
Does your child have any special dietary requirements? (Please tick)
Can the attendee swim? (Please tick) Are there any Court Orders etc that we should be aware of with regards to attendee (eg. Child Protection orders, involvement in juvenile justice, current bail conditions)? If so, please provide details:
Specific Activities
In attending the activity or camp, you consent to your child’s participation in a range of general sporting and
recreational activities. If particular risk-orientated activities are included, the organisers will have informed you of these. Are there any specific activities that you DO NOT wish your child to participate in? If yes, please specify: Consent to medical attention: I, the undersigned confirm my consent to the activities my child will engage in while
on a Young Life activity or camp. I acknowledge the staff and volunteer agents of Young Life wil take all possible care but cannot be held responsible for unforeseen accident or illness arising. I hereby consent to medical, hospital, rescue procedures being employed in the best interests of my child and that I shal be notified as soon as possible should the continuance of such procedures be necessary.
Disclaimer: In the unforeseen event of personal injury or il ness sustained while on a Young Life activity or camp, or
the loss of personal property except where such property was held in the custody of Young Life staff or volunteer agents when lost while on a Young Life activity or camp, I hereby release, and exempt, and indemnify the organisers, sponsors, and al other persons involved in the organisation of the Young Life camp, trip, excursion, from all action, proceedings, demands, costs, expense, and claims whatsoever made or taken by any person arising out of my child’s participation in such camp, trip, or excursion.
Discipline: If in the event your child's behaviour is deemed by the organisers to be inappropriate or compromises the
safety and/or health of other Attendees on the camp, trip or excursion, then Young Life reserves the right to send your child home, at your expense, at the earliest possible time, by the most effective mode of transport, in The personal contact/address details you supply on this form wil be entered into our database. We may use it to send you further information about Young Life Australia. Young Life Australia adheres to the Privacy Act and will not disclose this information to third parties. If you would like to know what information Young Life holds about you ☐ I do not wish to be added the mailing list.

Source: http://younglife.org.au/docs/YL%20Activity%20Medical%20Form%20under%2018%20summer%20camp.pdf