You are on page 1of 6

AIS Camp Registration Form

Year: 6 Venue: Madagui Date: 19-21 o! 2"1#

Important dates $ in%ormation:
&'ease (omp'ete and return t)is %orm to Re(eption no 'ater t)an: Frida* +1 ,(t 2"1#
&assport $ Visa
Please attach a photocopy of your passport photo page (this must
be of the passport your child will travel with on this trip)
Your passport must be !a'id unti' at 'east 22 Ma* 2"10
Submit your original passport to Reception before +1 ,(t 2"1#
(we will carry this on your childs behalf and return it to you after
the trip)
NB. If your child does not have a passport yet, then you must
complete these requirements using the students birth certificate.
&assport $ Visa
.A'' ot)er
Please attached a photocopy of your passport photo page & Visa
for Vietnam (this must be of the passport your child will travel with
on this trip)
Your passport must be !a'id unti' at 'east 22 Ma* 2"10
Your !isa %or Vietnam must 1e !a'id during t)e period o%
tra!e' .19 21 o!/
Submit your original passport & visaresidence card for Vietnam
to Reception before +1 ,(t 2"1# (we will carry this on your childs
behalf and return it to you after the trip)
Page | 1
Student In%ormation:
!amily "ame#
$iven "ame(s)#
Passport number#
"ationality of
Passport e%piry date#
Visa for Vietnam
e%piry date#
2mergen(* Conta(t In%ormation:
&arent 3
'ome (obile
)mail address#
*oes this person understand (written and spo+en) )nglish well,
Yes "o
'ome (obile
)mail address#
*oes this person understand (written and spo+en) )nglish well,
Yes "o
(different to
'ome (obile
)mail address#
*oes this person understand (written and spo+en) )nglish well,
Yes "o
Student Co''e(tion In%ormation
-he camp will finish outside of the normal hours of school. /n order for students to be collected
from their usual campus0 they will only be released to the person listed below who will need to
sign our student roll when they collect your child. -he bus will arrive at 1.23pm and the adult
collecting the student must be there no later than 1.43pm
"ame of adult collecting
to student
&ontact number
5lternative contact
Page | 2
&ain re'ie% &ara(etamo'
/f your child re6uires pain relief medication0 please indicate your preference for the action to be
ta+en by staff# (tic+ one)
Staff to administer when identified as re6uired by 6ualified first aid staff or when
re6uested by your child. (preferred option)
Staff School to contact you see+ing permission prior to administering pain relief.
ote: 7hile the school will ta+e due care to minimise ris+s to all students during school camps0
5/S will not be held responsible for any personal in8uries or damage to loss of material goods
incurred during the camp. /n signing this form you authorise the camp leader to see+ medical
assistance if re6uired on behalf of your child.
S56D25 A4R22M25
/ 999999999999999999999999999999999999999999999990 agree to follow the directions and
instructions of the teachers0 and the camp leaders. / agree to follow school rules and be
responsible0 considerate0 and sensible at all times. / will complete the re6uired reflections0
evaluations and assignments both on camp and on my return. / will not place myself or others
at ris+ and will maintain the reputation and standards of the school at all times.
Signature# 99999999999999999999999 Student name# 9999999999999999999999999
*ate# 999999999
/ agree that my child (insert name) 9999999999999999999999999999999999999 will be
participating in AIS Y6 (amp to Madagui on 19-21 o!em1er 2"1#.
/ am aware that personal or property damage ris+s may be associated with some or all of these
activities. / understand that all possible precautions will be ta+en to ensure my childs safety and
/ agree that the school0 staff0 and contracted employees shall not be in any way liable0 or
directly or indirectly held responsible for any in8uries0 loss or any other damages incurred0
whether to person or property.
(y signature below indicates that / understand all the associated ris+s and conditions as stated
Signature# 999999999999999999999999999
Parent$uardians name# 99999999999999999999999999999 *ate# 999999999
Page | 3
P5R-/&/P5"- "5()#
Please list any foods that you cannot eatdrin+ with a brief e%planation.
Does *our ()i'd su%%er
Yes 3
Causes and 5reatment
5llergies &omplete 5llergic Reaction (anagement section (Page :)
5naphyla%is &omplete 5llergic Reaction (anagement section (Page :)
5sthma &omplete 5sthma Plan section (Page 1)
)pilepsy !its ;ther
'eart &ondition
(uscular <oint =ac+
Psychological 5n%iety
-ravel Sic+ness#
'eadaches (igraines#
Sleep 7al+ing#
=ed 7etting#
;ther /ssues (Please list)
&an swim 13 metres,
(circle one)
"ot at all 7ith difficulty )asily
Page | 4
&'ease 'ist a'' medi(ations *ou :i'' 1e ta;ing during t)e trip 1e'o:<
ame o% Medi(ation Met)od Dosage= timing $ %re-uen(*
9 A'' medi(ation must 1e gi!en to t)e (amp 'eader %or sa%e ;eeping and
administering< &'ease ensure a((urate in%ormation regarding *our ()i'd>s name= timing=
%re-uen(* and dosage are pro!ided in :riting<
For medi(ations t)at students se'%-manage= p'ease pro!ide :)ere possi1'e= t:o
-uantities o% t)e medi(ation< 5)e se(ond -uantit* :i'' 1e (arried 1* sta%%= ?ust in (ase a
student 'oses t)eirs<
AS5@MA &7A
Please tic+ the relevant sections below to show +nown triggers0 usual symptoms and signs
that the asthma is getting worse0 that your child usually e%hibits.

Ano:n ast)ma

6sua' s*mptoms o%
8orsening s*mtoms
)%ercise 7hee>ing 7hee>ing
&oldsVirus -ightness in chest -ightness in chest
Pollens &oughing &oughing
*ust *ifficulty =reathing *ifficulty =reathing
;ther# *ifficulty Spea+ing *ifficulty Spea+ing
;ther# ;ther#
/s preventative medication used regularly,
*oes the participant always carry the medication with them,
*oes the participant need assistance ta+ing their medication,
ame o% Ast)ma
Met)od Dosage= %re-uen(* $ timing
Page | 5
A772R4IC R2AC5I, MAA42M25
'ave you ever suffered an allergic reaction to#
/nsect bites
Plant Pollen
*etergents or cleaning agents
!ood groups or additives
;ther triggers 99999999999999999999999999
I% *ou )a!e ti(;ed an* o% t)e a1o!e= t)en it is re-uired t)at *ou %i'' in t)e neBt
se(tion o% t)e A''ergi( Rea(tion Management<
See+ the advice of your medical practitioner if necessary when completing this form.
7hat are the triggers allergens that your child is allergic to,
7hat are the signs and symptoms of the reaction,
'as your child at any time suffered from? (5ICA appropriate bo%es)
5 localised reaction (any rash0 itching0 swelling at the site the poison has entered)
5 systemic reaction (any rash0 itching swelling away from the site where the poison has
5n anaphylactic reaction (severe breathing problems0 swelling of the body0 emergency
.=een hospitalised due to an allergic reaction,
/s adrenaline (e.g. adrenaline in8ection0 medi@epihaler0 epi@pen) administered when your child
suffers from an allergic reaction, Yes "o (Please circle one)
7hat medication does your child ta+e (if any) for prevention against an allergic reaction,
7hat treatment is followed for your child0 if an allergic reaction occurs,
5ll medication for the sufferers allergic reaction must firstly be noted on the medical form
and then brought on the camp by the participant and given to the camp leader.
I% *ou )a!e e!er eBperien(ed an anap)*'a(ti( rea(tion .se!ere 1reat)ing pro1'ems=
s:e''ing o% t)e 1od*= emergen(* situation/ or 1een )ospita'ised due to a''ergi(
rea(tion t)en *ou must (onsu't :it) *our medi(a' pra(titioner a1out *our
parti(ipation in t)is (amp prior to (omp'eting t)e registration %orm<
Page | 6