JC CAMP 2015
"Be Your BEST"
10 – 12 July 2015
REGISTRATION FORM
Completed forms can be emailed to [email protected]
Child Name (1): ___________________________
Age: _________________ M/F
Child Name (2): ___________________________
Age: _________________ M/F
Child Name (3): ___________________________
Age: _________________ M/F
Parent Name (1):________________________________________________
Email Address: ___________________________________________________________
Home Phone: _______________________ Work Phone:________________________
Mobile: ________________________________
Parent Name (2):_______________________________________________
Email Address: ___________________________________________________________
Home Phone: _______________________ Mobile:______________________________
Emergency Contact Details
(Other than those already listed above who are authorised to collect the child and
can be contacted in an emergency)
Name:_______________________________________________________________
Relationship to child ______________________________________________________
Home Phone: _____________________ Work Phone: ___________________________
Mobile: _________________________________
Payment Details
Please circle:
$175 early bird / $190 full price
(Please make cheques payable to Chinmaya Mission Australia Pty Ltd).
Credit Card Payments Only
Please select:
Visa
Mastercard
Bankcard
Name (as it appears on card): _______________________________
Card Number:
Expiry Date: ___ / ___
Signature:__________________________________________
Amount Enclosed: $ _____________________
The Chinmaya Mission (Charitable) Operating Trust
ABN 63 224 595 801
Release of Liability
“Be Your BEST” JC Camp 2015
Participant’s Name:
Father’s Name:
Mother’s Name:
Medical Details or Allergies
we need to be aware of:
Doctor's Name:
Doctor's Number:
List of Medications:
I _______________________ give permission for my child ______________________ to participate in the
Junior Chyk Camp 2015 at Don Bosco Camp, Victoria. I hereby release Chinmaya Mission Australia, its staff and
volunteers from any responsibility and liability for any illness or injury that my child may sustain during this
activity, including but not limited to accidents, any natural calamities due to act of God, food allergies and food
poisoning.
I release Chinmaya Mission Australia from any and all liability for damage to or loss of personal property,
sickness or injury which may occur while participating in this project. I am aware of the risks of participation,
which include and not limited to all of the above.
I authorize Chinmaya Mission Australia in the event of injury or illness of my child(ren) to obtain medical
assistance as required and I agree to meet all associated fees and charges. In the event my child is injured or
becomes ill during the program, either an authorized person or myself shall collect my child(ren) as soon as
possible.
I understand that in the unexpected event that the project has to be cancelled, I will not be eligible to any refunds.
I consent/do not consent to my child and his/her work being photographed and the photos being used to promote
other events.
Parent’s Signature
(Print Name & Date)
Parent’s Signature
(Print Name & Date)