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2. campers and rvs

ABCRA YOUTH CAMP
DATE:
14th, 15th & 16th April 2015 (during school holidays)
LOCATION:
INVERELL SHOWGROUND
AGE:
6 TO U17
FIRST 50 ENTRIES ACCEPTED
 COVERING : Campdrafting, Cutting, Cattle Selection, Rules, Theory,
Sporting Events, Stock Rider, Working Patterns, Horse Preparation,
Time trials and Animal Nutrition
 Leading instructors booked, cattle, bison and mechanical cow will be used.
 Includes some meals and off horse activities
 School participants will be limited to 3 horses per rider
 The appropriate clothing, saddlery, tack and AS3838 Helmets must be used
at all times
 Camping on Showground will be $12.50 (for duration of camp) payable to
the Inverell Showground Trust
 Riders must be a member of the ABCRA (day memberships available)
 Full payment is required to secure your place
 Please make cheques payable to : Inverell Junior Rodeo or Direct Debit Acc:
 Inverell Junior Rodeo :
BSB: 062 556
Acc No: 10281254
Contact Details:
Ron Berkley
PO Box 225
INVERELL NSW 2360
0417 612 660 or [email protected]
ENTRY FORM
ABCRA YOUTH CAMP – INVERELL 2015
14th, 15th & 16th April 2015
Age of entrants must be 6 – U17 and a financial member of the ABCRA
Contact Details
Name:________________________________________ DOB:___________ AGE:_________
Address:____________________________________________________________________
___________________________________________________________________________
Town:__________________________ P/Code:__________________
ABCRA Membership No:___________________
Ph:_________________________
Fax:________________________________
Mobile: ____________________________________________________________________
Email: _____________________________________________________________________
Please indicate - Level of Experience (circle)
Level 1 – Beginner
Level 2 – Some Experience
Level 3 – Experienced
I wish to participate in the ABCRA Youth Camp, and will abide by the conditions of entry.
Signature of Parent Guardian: _________________________________________________
Name of Parent Guardian: ____________________________________________________
Please indicate whether the parent or guardian is attending: YES / NO
COST IS $185.00 – PAYMENT TO BE MADE IN ADVANCE
Payment is by Cash, Cheque or Direct Deposit
Please return this entry form with payment and completed medical form to:
Ron Berkley
ABCRA Youth Camp
PO Box 225
INVERELL NSW 2360
INVERELL JUNIOR RODEO INC.
PO Box 225, Inverell NSW 2360
ABCRA YOUTH CAMP
14th, 15th & 16th April 2015
MEDICAL & AMBULANCE AUTHORISATION
CHILD’S NAME:
IMPORTANT NOTE:
You are required to disclose all information relating to any medical conditions and treatment your child is currently
undergoing.
1
Medication brought to camp must be in the original packaging, and should have the child’s name,
dosage, and dosage times, clearly marked. Only medication originally packaged and in the
child’s name, will be administered. An asthma management plan must be provided for all
asthmatic children.
2
A copy of any special diet ordered by you or a doctor, should be given to Catering Committee.
Please answer the following questions about your child, by circling the correct answer:
1. Does your child have a disease, disability, medical or other health condition which may affect
her/his ability to participate in the Camp program?
Yes/No
If yes, please give details of all conditions, attaching a separate sheet if necessary:
2. Does your child suffer from any of the following?
a) Asthma
Yes/No
e) Skin Conditions
b) Diabetes
Yes/No
f) Epilepsy, fits, blackouts
c) Sleep Walking
Yes/No
g) Allergic Conditions
d) Bed Wetting
Yes/No
h) Attention Deficit Disorder
If yes, please provide full details, attaching a separate sheet if necessary:
3. Has she/he been sick or treated by a doctor for any illness in the past four weeks?
If yes, please provide full details, attaching a separate sheet if necessary:
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
4. Is she/he taking any medication at present?
Yes/No
If yes, read and complete the following and attach a separate sheet with instructions from
prescribing doctor.
Name of medication:___________________ Dosage: _______________________________
Times to be Taken: ____________________ Reason/Condition: ______________________
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5.
Does your child have an allergic reaction to any type of medication or food?
If yes, please give full details, attaching a separate sheet if necessary.
Yes/No
6
Has she/he had the Combined Diphtheria Tetanus Toxoid booster injection?
Yes/No
If the answer is yes, in what year was the last booster injection given? 19…….. / 200…
7.
Has she/he been immunised against measles?
Yes/No
(N.B. Homeopathic “immunisation” is regarded as not “immunised” by the National Health and Medical Research Council).
8.
Do you agree to your child being given Paracetamol, if necessary?
Yes/No
It is your responsibility to provide all medication as originally packaged, comprehensive instructions and equipment for its
administration and adequate supply for the duration of Camp. Medication is kept secure and self administered by the children,
under direct supervision of Camp officers at specified times. PLEASE CONTACT THE COMMITTEE IMMEDIATELY IF
YOUR CHILD HAS ADDITIONAL NEEDS.
DOCTOR’S NAME: _______________________________________ Phone no: _______________
Address: _________________________________________________
YOUR MEDICARE NUMBER IS REQUIRED FOR YOUR CHILD TO RECEIVE IMMEDIATE MEDICAL
ATTENTION, IF NECESSARY.
Medicare No: ____________________________
Health Card No: _________________________
Private Health Fund: ______________________
Fund Number: ____________________
Ambulance Cover: Y/N
I agree to my child’s attendance at the above-mentioned Camp and to his/her taking part in any activities and excursions arranged
for the children in connection with the Camp program. I also authorise designated Camp officers to supervise administration of
medication by my child as requested by me on this form. In the event of any accident or illness, I authorise the obtaining of such
medical assistance on my behalf that my child may require. I also undertake to pay medical fees and/or costs of drugs which may
be incurred while my child is at the Camp.
I hereby release and indemnify the Inverell Junior Rodeo Inc. and its officers against all actions, suits, claims, demands,
proceedings, losses, damages, compensation, costs, charges and any expenses whatsoever in respect of any personal injury of or
any infringement, disturbance or destruction of any rights of any person including myself and my son/daughter/ward arising
directly or indirectly out of the aforementioned administration of medication.
Please sign below to indicate your agreement to the above conditions.
__________________________________
_____________________________________
Signature of Parent or Guardian
Date:
Print Name of Parent or Guardian
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