Camp Footloose

PART A – PERSONAL DETAILS OF CHILD

Child's Details*

First Last

Age at October 2024*

Height (in cms)*

Weight (in kgs)*

Child's gender*

Address*

Street Address Address Line 2 Suburb State Postcode

School year currently in*

Parent/Guardian's Details*

First Last

Contact Number - Home

Contact Number - Mobile

Contact Email*

Additional Emergency Contact*

First Last

Contact Number - Home

Contact Number - Mobile

Family Doctor's Name*

Family Doctor's Contact Number*

Rheumatologist's Name*

Rheumatologist's Contact Number*

Health Insurance Fund

Health Insurance Member Number

Medicare Number

Expiry Date

Who will be taking & picking your child up from camp?
Please note Arthritis NSW staff require sign in/sign out of all Camp Footloose attendees. Any changes to the contact details below, please notify the program coordinator on 02 9857-3300 or camps@arthritisnsw.org.au of these changes.

Drop-off*

First Last

Contact Phone Number*

Pick-up*

First Last

Contact Phone Number*

Please list any known allergies (including food, medication, plants, etc)

If these allergies are severe, or may cause anaphylaxis, please include details about the management of these allergies.

IF THE ALLERGY REQUIRES POTENTIAL USE OF AN EPI-PEN, IT IS EXPECTED THAT YOUR CHILD WILL CARRY HIS/HER OWN WITH THEM AT ALL TIMES AND BE ABLE TO ADMINISTER THE EPI-PEN.

Please confirm which type of Juvenile Arthritis (JIA) your child has:*

Systemic Onset

Psoriatic Arthritis

Pauciarticular/Oligoarthritis

Polyarticular RF+ve

Polyarticular RF-ve

Juvenile Lupus

Enthesitis Related Arthritis

Don't know

Other

Age when diagnosed?*

Which joint(s) are affected?*

If any, what splints are used and when?

Is any special equipment required by your child?*

E.g. Walking stick, wheelchair.

If yes, please specify what type?*

*Please note all equipment required will need to be provided by parent/guardian

How often is it used?*

Is assistance required with mobility/dressing/showering/toileting?*

If yes, please the assistance required:*

Please tick any of the following that applies to your child:

Other (please specify)

If any of the above apply, please provide details including if/how condition is managed

Does your child have any developmental disability, behavioural disorders or social problems?*

e.g Anxiety

If yes, please advise of the behaviours we should be aware of and any management plans used by the school or your child might be involved with:

Please keep in mind, Camp Footloose is a camp for children with juvenile arthritis. Staff are not necessarily trained to deal with behavioural problems.

Are there any other physical, psychological, or emotional issues that we should know about?*

If yes, please advise what they are and how they are managed

Date of last tetanus immunisation

Is your child able to tolerate a tetanus immunisation?*

Are there any special requirements regarding diet?*

If yes, please specify the details:

Can your child swim?*

What is their level?*

Poor (not without floatation devices)

Fair (unassisted for 25 metres)

Strong (unassisted for 50 metres)

Has your child been to an ANSW camp before?*

What year/s?*

Is this the first time your child has been away from home alone?*

Is there anything your child is nervous about regarding camp?

How did you hear about Camp Footloose?

What time is your child’s normal bedtime?*

Room Allocations:

Child 1

Child 2

If your child has been to camp before and wishes to share a room with friends of a similar age, please provide the names of the two other children. All efforts will be made to allocate rooms based on this feedback, but this may not always be possible. Please explain to your child that they may not be able to have all their friends together.

Is there any other information you feel we should know to ensure your child enjoys the camp in every way possible?

What size Camp Footloose T-shirt is preferred?

PART B – PARENT AUTHORISATION

I, the undersigned, declare that I will not hold Arthritis NSW, its employees or volunteers responsible for any illness or injury to my child during Camp Footloose.

In the event of any injury or illness, I authorise Arthritis NSW staff to consent to emergency medical arrangements on my behalf, where it is impracticable to communicate with me, as is deemed necessary by a qualified medical practitioner. Such consent includes- anaesthetics, blood transfusions, and surgery and ambulance attendance. I will accept financial responsibility for any such action taken.

I recognise that this is a camp for children and that it is important for the children to meet with others in the absence of their parents in order to develop rapport. I agree to leave my child in the care of the Camp Footloose staff and will not make arrangements to visit until the end of the camp. I understand that I can remove my child from camp at any time. I agree to sign the attendance register held by the Camp Footloose coordinator (when pick up is face to face) when I take my child home at the end of camp or beforehand, should he/she wish to leave if they are missing home or for any other reason. I will advise the camp coordinator or Arthritis NSW if someone other than myself will be attending to pick up my child. I authorise Arthritis NSW to require the signature of this person upon picking my child up.

Parent/Guardian's Name

First Last

Date

PART C - MEDIA CONSENT

Arthritis NSW seeks parental / guardian consent to use media, including but not limited to, photography and video taken at Camp Footloose. We assure you that media materials will be used in a responsible and positive manner for the purpose of promoting the organisation’s activities and to secure funding for future camps. Please indicate below where you give consent for media to be used, complete your name and your child’s name and accept the consent.

If you wish to withdraw this consent at any time, please contact Arthritis NSW on (02) 9857 3300.

Arthritis Matters (member magazine of Arthritis NSW)*

Mainstream media (e.g. local newspapers, family magazines, radio)*

Social media: Facebook, Twitter, Instagram, YouTube*

Arthritis NSW Website and Newsletters*

Arthritis NSW Sponsor / Corporate Partner marketing materials (i.e. Camp Footloose funders)*

Paediatric Rheumatology Network*

I, (Parent/Guardian name)*

First Last

of (address)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

permit media of my children / children in my care, to be used as indicated above. (Child's name)

First Last

Date

USE OF ADULT’S PHOTO CONSENT
If required, photo/video may occur during drop off/pick up times.

I permit media of me to be used as indicated above if required.

First Last

(Adult’s name 1)

I permit media of me to be used as indicated above if required.

First Last

(Adult’s name 2)

PART D – CAMP GUIDELINES

To ensure the safety and enjoyment of all campers we have included a behavioural contract for both you and your child to sign. It is an assumption that by signing this form your child will adhere to the following guidelines. Applications will not be accepted without this signed form by both child and parent/guardian.

CAMP FOOTLOOSE GUIDELINES

Campers must follow and adhere to the directions and requests of all staff members
No camper is to leave the campsite without a leader.
No alcohol or smoking is allowed on camp-site for any camp members.
No bullying or threatening behaviour will be tolerated from any camp members. Everyone’s needs and individuality must be respected.
Personal property of other camp members, volunteers, leaders and the camp environment must be respected.
All rooms are to be kept tidy.
During any free time, all campers must stay within designated areas as outlined by camp staff.
No male and female campers are allowed together in a bedroom/cabin without a leader present.
No camper is to enter another camper’s room without permission from that room’s leader.
Campers are to be present at all mealtimes and activities, unless given permission from a leader or parent who has advised the camp coordinator to exclude the child.
Shoes are to be always worn at all times out of doors and in the dining room.
Sunscreen and a hat are to be worn when outside during daylight hours.
No camper is allowed personal penknives or other dangerous implements.
Mobile phones are not to be taken to sessions (child may request the use of the phone if they need to make an urgent phone call). Mobile phones can be handed to group leaders for safekeeping.
Campers are discouraged from bringing iPods and other expensive equipment to camp. If they choose to do so, these items are the sole responsibility of the camper.

DISCIPLINARY STEPS

Verbal warning.
Meeting with leader, camper, and camp coordinator; time out/miss out on one activity.
Phone parents – leader or camp coordinator informs camper’s parents that the camper has one last chance before they will be asked to come and collect them from the camp site.
The child is sent home. Arthritis NSW staff will contact the child’s parents and ask them to make arrangements, to collect their child from the campsite immediately.

We do not anticipate any problems if the above guidelines are followed so that everyone has an enjoyable time.

Date

PART G – MEDICATION CHART & PHOTOS

Please upload the completed Medication Chart*

Max. file size: 50 MB.

To ensure the safety and well-being of all campers, please adhere to the following medication management guidelines if your child requires medication during camp:

1. Complete the Medication Chart: Download and print the medication chart, and take it to your GP for completion. Ensure the form is signed by a medical professional. Once filled, scan and attach the document here as either a PDF or Word file.
2. Prepare Medications for Camp: All medications, including those taken as needed, must be provided in a Webster Pack. Note that medications not supplied in a Webster Pack will not be accepted, except for liquid medications.
3. Injectable medications will not be administered at camp. Please arrange for any necessary injections to be administered either before or after your child's time at camp.

Please upload a passport quality photo of your child*

Max. file size: 50 MB.

Name

This field is for validation purposes and should be left unchanged.

What is Camp Footloose?

Testimonials from Camp Footloose

October 2024 Camp Details

Location and Schedule:

Requirements:

Application Checklist

Application Form

PART A – PERSONAL DETAILS OF CHILD

PART B – PARENT AUTHORISATION

PART C - MEDIA CONSENT

PART D – CAMP GUIDELINES

PART G – MEDICATION CHART & PHOTOS