Life Exchange – Year 13 Registration

Camp*

Name*

First Last

Date of birth*

Gender*

Male
Female

Street address*

Suburb*

Postcode*

Email address*

Mobile phone*

Home Phone

Church that you attend regularly*

Role at camp*

Mainstream camper "buddy"

EMERGENCY CONTACT INFORMATION

Emergency contact person (e.g. parent, friend)*

Phone number of emergency contact*

Relationship of emergency contact to you*

MEDICAL AND DIETARY

Dietary requirements

Medical Information (that's relevant for us to know)

Any Medication?

Note: Medication can not be kept in the cabin - it will be stored in the First-Aid room.

PERSONAL FAITH

How would you describe your relationship with God?*

Are there any reasons why you would be unsuitable to be on camp at this time?*

REFEREES

Please give the details of 1 referee who know you well and who we can contact if needed (e.g. pastor, youth pastor).

Referee name*

Referee contact number*

Referee organisation and position*

CHILD PROTECTION AND SAFETY

Working with Children Check number

This check is required for all campers 18 years and over.

Have there been any incidents that you were involved in, either directly or indirectly, which were of a child protection nature? Or have you ever, to your knowledge been accused of sexual misconduct or abuse?*

Yes
No

DECLARATION

Please read and confirm the following:*

If you are unable to tick all of these, please just let us know. Speak with your Camp Director or contact Bruce Marlin (bruce@campkedron.com).

I am committed to this ministry as an expression of my faith in Jesus and my desire to live as his disciple.
I agree to abide by the Camp Kedron Code of Conduct.
I will work under the leadership of the Director and will support him/her.
I commit myself to operate by biblical principles - serving in love, humility and unity.
I declare that I have not in the past participated nor do I currently participate in any physical or sexual abuse.
I currently do not participate in any premarital or extramarital sexual relationships, serious dishonesty or other serious moral lapses.
I confirm that the information provided in this application is true and correct.