Parent/Guardian Details:

First name

Last name

Mobile Phone

Email

Address

Defence ID

Participant's details:

Participant 1 (name, date of birth, gender):

Participant 2 (name, date of birth, gender):

Participant 3 (name, date of birth, gender):

Participant 4 (name, date of birth, gender):

Participant 5 (name, date of birth, gender):

Participant 6 (name, date of birth, gender):

Which course would your participants like to climb? Kids Course (minimum 100cm tall), or Grand Course (minimum 135cm tall)?

Please advise selected course for all participants:

Medical Information: YMCA SA works hard to provide safe, supported and enjoyable camps and activities. Please help us to meet this goal by providing us with as much information about medical, health, behavioural and dietary issues or concerns as you can. Our staff are very happy to discuss any additional requirements or support that is needed.

Does any of the listed participants have any allergies and/or dietary requirements?

Yes

No

If yes, please outline any dietary requirements below.

Does any of the listed participants have any medical conditions or issues that may affect their participation in this activity?

Yes

No

If yes, please outline any medical conditions below.

Does your family have Private Health Insurance?

Yes

No

If yes, please give details of the provider, number and expiry date.

Does your family have Ambulance Cover?

Yes

No

Emergency Contact Name

Emergency Contact Phone Number

Emergency Contact Email

Additional Comments or Queries

Image Consent

I agree for my families photograph to be taken, acknowledging that it may be reproduced in print and electronic format for YMCA South Australia promotional activities. I understand that I may request in writing for my families photograph no longer be used in future print or electronic media.

Yes, I agree

No, I do not agree

Defence - explorers form

Image Consent