sole parent

FAMILY CAMP
24 TO 26 SEPTEMBER 2010
PHILLIP ISLAND COASTAL DISCOVERY CAMP

Liberty
FAMILY CHURCH
 sole parent

FAMILY CAMP
The first sole parent family camp has been put together to provide a weekend retreat for mother's and their
primary school aged children - a break from the regular routine of life. The camp is designed to provide
support to sole-parent families, many of whom have been affected by the recent bushfires and face on-going
challenges.

The weekend will include activities for the whole family to enjoy together, fun activities just for the kids, and
two positive parenting sessions to equip parents.

Meet other families and form new friendships that will last beyond the weekend. Enjoy a weekend away at
Phillip Island and create positive family memories.
Dates Program
Friday 24 to Sunday 26 September 2010. Friday 24 September
5:00 pm Depart Healesville from Liberty Family Church
Who 6:00 pm Picnic dinner at Koo-Wee-Rup
This camp is for sole parent (mother’s in this case) families 8:00 pm Arrive at campsite and supper
and their primary-school aged children. Due to supervision
and sleeping requirements, we regret that we are unable to Saturday 25 September
include pre-school aged children. 8:00 am Breakfast
8:30 am YMCA family beach carnival (All)
Location 10:30 am Morning tea
Phillip Island Coastal Discovery Camp, 73-77 Marlin St, 11:00 am YMCA kids program (Children)
Smith’s Beach, Phillip Island. Positive parenting session one (Mothers)
Campsite phone (03) 5952 2467. 12:30 pm Lunch
1:30 pm Family tidal exploration
Transport 3:30 pm YMCA kids program (Children)
Transport to and from the campsite will be provided by Coffee afternoon / free time (Mothers)
coach, leaving from Liberty Family Church, corner Lilydale 6:00 pm Dinner
and McGrettons Road, Healesville. A picnic dinner will be 7:00 pm Torch-lit beach walk
provided on Friday night. 8:30 pm Family movie

What to bring Sunday 26 September

Sleeping bag or sheets and doona, pillow, bath towel, beach 8:00 am Breakfast
towel and bathers, personal toiletries including sunscreen, 8:30 am Family activity by the YMCA (All)
shorts, t-shirts, windcheater, tracksuit pants, warm jumper/ 10:30 am Morning tea
jacket, waterproof jacket, sleep wear, hat, runners, water 11:00 am YMCA kids program (Children)
sandals/old runners, camera. Positive parenting session two (Mothers)
12:30 pm Lunch
Accommodation is in dormitory style bunk houses. Mother’s 1:15 pm Pack up
will be accommodated with children. 2:00 pm Depart camp

Cost Please return completed forms,

$50.00 per family. Payment can be made via cash or along with $50.00 payment to:
cheque. Family Camp
C/- The Salvation Army
For further information PO Box 455
Contact John Meadth on (03) 5962 2206, HEALESVILLE VIC 3777
Graeme Mawson on (03) 5962 4826 or
email healesville@aus.salvationarmy.org This camp is sponsored by
YMCA Victoria
The Salvation Army
Liberty Family Church, Healesville
CONFIDENTIAL REGISTRATION FORM

sole parent
FAMILY CAMP
Personal Contact Details

Mother’s Given Name Surname:

Preferred Name Date of Birth:

Address

Suburb Postcode Phone ( )

Child 1 Given Name Male / Female Date of Birth:

Child 2 Given Name Male / Female Date of Birth:

Child 3 Given Name Male / Female Date of Birth:

Child 4 Given Name Male / Female Date of Birth:

Do you consent to appropriate use by us of photographs taken on the program that include you and/or Yes / No
your children? For example, inclusion in our newspaper, placement on our web page or in
a brochure.
Would you like to be informed of children and family activities of the camp sponsors? Yes / No

Program Preparation Details

Dietary Requirements:
Do you or your children have any special dietary requirements? Yes / No
If so, please list them: (We will endeavour to meet these requirements, and will contact you if necessary)

Safety and Care Details

In case of an emergency, please list phone numbers where you and a friend or relative may be contacted during the
course of the program.
Name Relationship Phone Number

Information on Relevant Conditions

Are there any conditions which require special attention that we should know about, e.g. hearing or sight impairment,
ADD or ADHD, behaviour issues, formal counselling situations, or any other? Please list below:

Protecting Your Privacy

Protecting your privacy is important to us. The information we seek allows us to manage risk, provide reasonable care and administer your involvement in
our program. We are careful to keep your information confidential, and provide it only to those agents acting on behalf of the organisation who need it to
enable them to perform their agreed activities (e.g. the First-Aider-In-Charge). You are welcome to contact our office in relation to issues regarding your
personal information and for a copy of our Privacy Policy.
We only ask for information that is necessary for the purposes outlined in this statement. In some circumstances, if you don't provide us with all requested
information, you could miss the opportunity to be involved in our program.
 Medical Information Please give details of your medical insurance if applicable
Insurance Provider Membership Number:
Medicare Number: Expiry Date:

Do you have ambulance cover? Yes / No Health Care Card Number (if applicable):
Important: Please note that in regards to non-prescription medications such as paracetamol (e.g. Panadol), it is our
policy that leader team members do not provide medications.
Will your child(ren) need to take any tablets or other medication during the course of the Yes / No
program?
If yes, please give details: _____________________________________________________
Has your child been taken off medication recently? If yes, please give details? Yes / No

Please give details of your child(ren’s) last tetanus injection(s):

Has your child previously broken/fractured any bones? If Yes, please give details: Yes / No

Specific Medical Conditions

Please indicate if your child(ren) has had any of the conditions below. Provide additional details if necessary.

Condition In the Present Details Condition In the Present Details:

Past Past

Asthma Hyperactivity
Appendicitis Hypo activity
Bronchitis Heart Problems
Chicken Pox Measles
Diabetes Mumps
Ear Infections Pneumonia
Epilepsy Tonsillitis
Fits/Convulsion Allergy – foods
Faint/Dizziness Allergy – animal
Glandular Fever Allergy – other

Particular Activities
In attending the program, you consent to your child's participation in a range of general sporting and recreational
activities. If potentially risky activities of a specific nature are included, the Team Leader will inform you of these.
Are there any specific activities that you do not wish your child to participate in? Yes / No
If yes, please specify:

Your Agreement with the Organisers

I am aware, in signing this document regarding my child’s participation this program, that certain elements of the
program could be physically and emotionally demanding. Furthermore, I understand that certain inherent risks and
dangers may exist in the activities in which my child(ren) will be participating. I acknowledge that while the organisation
and its leaders will make every reasonable effort to minimise exposure to known risks, all hazards and dangers
associated with these activities cannot be foreseen or may be beyond the control of the organisation, its leaders and
staff. In the event of any emergency where my nominated contact people are unavailable:
1. I authorise the leaders to obtain medical advice and/or assistance which they deem necessary.
2. I further authorise qualified practitioners to administer anaesthetic if required.
3. I accept all operation, blood transfusion and/or anaesthetic risks involved in the event that such procedures are
deemed necessary.
4. I accept the responsibility for payment and agree to pay medical, transport and any other related expenses.
5. I confirm that the information contained in this application is true and correct.
6. I agree to inform the leader of any change to these details.

Name of Caregiver Signature of Caregiver Date