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Camp Caution Letter. IMPORTANT!
YOU CANNOT GO IF THIS FORM IS NOT SIGNED
Assalamualaikum
The nature of the Man Vs Wild Camp at Mt Remarkable organised by the Islamic Information Centre of
SA on the 12th to the 15th of April 2015 is a physical and mentally testing event. For this reason we are
asking you, the parent and the child to think carefully before applying.
This is a a camp designed around pushing the youth out of their comfort zones and closer to the natural
world. There will be times when they will be pushed mentally and physically beyond their usual activites.
There will be activites that the youth might not like or agree with. If any of the above is a problem or
you/your child has a problem obeying orders, DO NOT COME. It will be detrimental to your child if they
are left behind because they cannot keep up with the physical requirement or are adversely affect the
group with their behaviour.
Please take this into consideration when applying and if your application is unsuccessful.
If you have any queries relating to this please contact Saad on 0426 451 393 if you have any concerns.
Jazakum Allah khair
IICSA camp committee
I, .................................................................. agree to send my son to the camp and understand the possible
risk associated with this camp if camp rules are not followed.
Parent/Gaurdian Signature........................................................................ Date.........../............./............
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APPLICATION FORM
APPLICANT’S DETAILS:
(One person per application form)
MALE [ ] FEMALE [ ]
FAMILY NAME:__________________________________________________
DATE OF BIRTH: ____________
FIRST NAME:___________________________________________________
YEAR OF STUDY IN 2013: ____
ADDRESS:_____________________________________________________
PH: ________________________
_________________________ STATE:_______ POSTCODE: [
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MOB: ______________________
emails: ________________________________________________________
OCCUPATION: STUDENT [ ] OTHER ______________________________
IF STUDENT, NAME OF SCHOOL/UNI: ______________________________
MEDICAL CONDITION(S): ____________________________________________________________________
NEXT OF KIN’S DETAILS : (in an emergency)
FAMILY NAME:__________________________________________________
LEVEL OF RELATIONSHIP:
OTHER NAMES:_________________________________________________
_________________________
ADDRESS:______________________________________________________
CONTACT TELEPHONES:
________________________ STATE:________ POSTCODE: [
PH: ______________________
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]
MOB: ____________________
INDEMNITY & CONSENT:
I, ........................................................................................................... the applicant, do state as follows: 1. I irrevocably authorise
the organisers of the camp to consent, where it is impractical to communication with me, for my son/daughter (the applicant) receiving
medical or surgical treatment as may be deemed necessary. 2. I irrevocably authorise the organisers to use his/her Medicare number
for the above purpose. Medicare No. : [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] 3. I will not hold the organisers of the camp,
team leaders and IICSA in any way liable for any injury and/or loss occasioned by my child and I hereby release the organisers,
team leaders and IICSA from liability for any injury and/or loss.
APPLICANT’S SIGNATURE: _____________________________ DATE: _______________
Please pay Saad kalaniya P: 0426 451 393 the sum of $100 in cash (NO cheques/money orders)
flat rate for each applicant (price may vary with sibling/family bookings) Payment includes transportation, camp accomodation and meals.
Application form & full payment must be received no later than FRI 3rd of April 2015. Applications received after the closing date
will placed on a standby list. (Please do NOT send cash in the mail, give it personally). Receipt of application form and payment prior to
closing date does not guarantee acceptance to the camp. Acceptance subject to written confirmation by the Islamic Information Centre of SA.
Application forms can be emailed to [email protected] or handed in personally.
IICSA OFFICE USE ONLY:
DATE RECEIVED: _____________________________________
_______________________
RECEIVED BY (NAME): ________________________________
CATEGORY: ___________
SIGNATURE: _________________________________________
OTHER: _______________
AMOUNT: $____________________
RECEIVED: ___________________
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Meet at IICSA at 8:00AM Sunday for a 10:00am departure
We will not wait for late comers.
This Camp has limited spaces.
Please write down (in 100 words or less) why we should accept your application?
PLEASE BRING “EXACTLY” THE FOLLOWING:
- Sleeping Bag
- socks & underwear
- 2 jumper/long sleeve clothing
- 2 thin long sleeve tops/T-shirts
- 2 pants/shorts (1 to wear, 1 spare)
- Large pack biodegradable wet wipes per person
- Personal insect repellent
- 1 pair comfortable hiking shoes
- 1 Towel
- IF RAINING – waterproof full body jacket
- 1 spoon, 1 fork, foldable cup/metal cup
- SPF 50+ Sun cream
- 1 Hat and/or Beanie
- Medicine for 4 days (if required)
Please note, try to bring the lightest clothing you have as the lighter your bag is,
the easier it will be on you.
Camp Protocol
1. Any participant who consistently breaks the following protocols will be asked to leave.
2. Tolerance, kindness and mutual respect in the islamic spirit of brotherhood is expected.
3. In the spirit of the camp objectives we kindly ask you to leave behind disruptive
instruments which may cause a distrubance to others e.g, radios, ghetto blasters and
musical instruments of any kind.
4. Please remember to leave any old grudges, stinking attitudes or bad language at home.
5. Any material of obscene content such as pornographic magazines etc will not be tolerated.
6. Finally make the intention to enjoy this camp as a retreat with your beloved brothers
Lets have some fun!
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Medical Notification Form
Have you ever had or do you currently have:
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Asthma, or wheezing with breathing, or wheezing with exercise?
Frequent or severe attacks of hay fever or allergy?
Frequent colds, sinusitis or bronchitis?
Any form of lung disease?
Pneumothorax (collapsed lung?)
History of chest surgery?
Claustrophobia or agoraphobia (fear of closed or open spaces)?
Behavioral health problems?
Epilepsy, seizures, convulsions or do you take
medications to prevent them?
Recurring migraine headaches or do you take
medications to prevent them?
History of blackouts or fainting (full or partial loss of consciousness)?
History of recurrent back problems?
History of diabetes?
History of back, arm or leg problems following
surgery, injury or fracture?
Inability to perform moderate exercise
(example: walking one mile within 12 minutes)?
History or high blood pressure or do you take
medication to control blood pressure?
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
This information I have provided about my medical history is accurate to the best of my knowledge.
Student Signature __________________________________________
Parent / Guardian Signature __________________________________
Date of Signature ____/_____/_____
Application forms can be emailed to [email protected] or handed in to IICSA personally.
NO FORM, NO PAYMENT, NO GO!