St Marks High School Camp 2011

IMPORTANT
Space is limited, therefore early registration is strongly recommended. Because of space
limitations we may not be able to accommodate all applicants.

Catherines Creek Camp

1st of September to 3rd of October
Cost: $140
(Save $10 for Brothers/Sisters)
Please Complete Details Below to Register:
Part 1. St Marks Camp Application

Camper Information
Name: ______________________________________________________________
(First)

Address:

(Last)

_________________________________________________________
_____________________________ ______________
(Suburb)

(Post Code)

Home Number: __________________________

Mobile Number: _________________________
Date of Birth: _____ /_____ /_____

Male Female

Year Level: ______________

Amount Enclosed: $_______

Check #_________ Cash

Who will be picking up your child on Return Monday 3rd of October at 5pm? Please
include Name and telephone.
_______________________________________________________________
(Please notify the camp organiser (Lucy Mankarios: 0431 424 797) if this changes.)

Part 2. Required Medical Information

CAMPER NAME: __________________________________________________________________

I understand that all reasonable precautions have been and will be taken for the safety of my child. I further
agree to hold harmless the servants of St Marks Coptic Orthodox Church against any and all liability, loss,
damages, costs or expenses which the above named child or I may sustain or incur.

MEDICAL INFO:
Does your child have any medical condition?
Yes No
If yes, please specify condition? _______________________________________
_______________________________________________________________________
Does your child take any medication?
Yes No
If yes, what & how often?
_________________________________________
_______________________________________________________________________
Is your child allergic to any specific food?
Yes No
If yes, please specify? _______________________________________
_______________________________________________________________________
Is your child allergic to any specific medication? Yes No
If yes, please list:
_______________________________________________
_________________________________________________________________
Other allergies?
Yes No
If yes, please list:
_______________________________________________
_________________________________________________________________
Has camper had operation or serious injury?
Yes No
Please list and give date: ____________________________________________
________________________________________________________________
List any chronic or recurring illness and any special emergency care normally given
(attach separate sheet if needed) ____________________________________________
______________________________________________________________________
Specify any normal camp activity that camper may not participate in: __________
______________________________________________________________________

Part 3. Parent / Guardian Information

Youth Name:

______________________________________________________

Parent / Guardian Name:

________________________________________________

Home Phone: ___________ Work Phone: ___________ Mobile: ________________

Emergency Contact Name: ______________________________________________
Relationship to Youth:

________________________________________

Home Phone: _____________________

Mobile: _____________________

Part 4. AGREEMENT
I am aware of the camp policies and guidelines. I understand that this is a church related camp and
that certain standards of conduct will be required of the camper. If accepted, I agree to abide by the
camp rules. I agree to demonstrate respect for the camp servants & staff at all times. I understand
that if I fail to keep my agreement, I may be asked to leave camp. I give permission to use pictures in
which I may appear in camp brochures, flyers, or other promotional literature, both electronic or
published and used by the camp.
YOUTHS SIGNATURE:

________________________________________________

CONFESSION FATHERS NAME:

__________________________________________

CONFESSION FATHERS SIGNATURE: ______________________________ DATE: ___/ ___/ ___

As parent / guardian, I have read the Camp Policies and Guidelines and reviewed them with my
child. I accept them and expect my child to abide by them. I will be responsible for any and all
property damaged by my child when he/she is at camp. In the event of an accident or serious illness,
I request the Camp Organiser to contact me immediately, grant permission for a licensed physician
and medical facility selected by the Director to take all necessary steps to insure my childs health. I
give permission to use pictures in which my child (as a camper) may appear in camp brochures,
flyers, or other promotional literature, both electronic or published and used by the camp.

PARENT / GUARDIAN SIGNATURE:

____________________________ DATE: ________

(Camper and Parent/Guardian signatures are required for camp attendance)