APPLICATION FORM: Summer School 2013 I wish to attend the above residential school to be held at:
Gilwell Park, Chingford, London, E4 7QW from the 24th – 29th August 2013 COST (please tick chosen option) Early bird offer - £180 (if form and payment is received by 15/04/2013) Full Price - £205 (form and £50 deposit by 15/04/2013, remaining balance by 29/07/2013) Camping price - £150 (over 18s only. £50 deposit by 15/04/2013, remaining balance by 29/07/2013)
DETAILS (please fill in all sections) NAME............................................ DATE OF BIRTH............................ AGE (as of 23.08.13)……... ADDRESS................................................................................…………………………………………… E-Mail……………………………………….
TELEPHONE NO....................................... …..
CORPS...................................…………….
DIVISION………………………………………..
MALE
FEMALE
ROOMS Please state here who you would like to share a room with. We cannot guarantee that you will share with all of your preferred options as we have to adhere to safeguarding policy, but we will do our best to accommodate your request.
1)…………………………………. 2)………………………………….. 3)…………………………………
OPTION. (please circle preferred option.) Note: an option may not run if there are too few people who take it up for it to be viable. If this is the case, you will be contacted and be able to make a second choice.
DRAMA CHORAL What part do you sing? ______________________________
ART
SPORT BRASS What instrument do you play?
______________________________
During the event you/your child will be involved in a variety of activities. In order to allow staff to be fully prepared, please indicate in the space provided below any special needs you/your child has which could affect your/their participation in some way during the event.
During the event we hope to take photographs. Please complete the form accordingly. If no mark is made, we assume that permission for photographs has been granted. As a parent/guardian of the named child, I give permission for him/her to: Be photographed and published Be recorded on Audio Visual and be broadcast
YES / NO YES / NO
PLEASE NOTE: Early Bird discount Application forms with FULL PAYMENT should reach Divisional Headquarters by 15th April 2013 if you are interested in receiving the early bird discount. Anyone who’s forms are received after this date will result in be charged full price. FULL PRICE or CAMPING If you are not able to provide full payment and receive the early bird offer, or are over 18 and wish to camp, please return a non-refundable deposit of £50 (cheque/postal order) by 15th April 2013. This will secure your (child’s) place at Summer School. The remaining balance must be paid by 29th July 2013. If you have any concerns about payment or application for Summer School, please contact Ben Still at DHQ. We really are very friendly and reasonable! PLACES WILL BE ALLOCATED IN STRICT ORDER OF RECEIPT WHILE PLACES ARE AVAILABLE IN THAT AGE GROUP. WHEN ALL PLACES ARE TAKEN UP, A WAITING LIST WILL BE INITIATED.
Please make cheques payable to: ‘The Salvation Army’. Return to:
Summer School 2013, The Salvation Army, Maldon Road, Hatfield Peverel, Essex, CM3 2HL
Delegate Signature......................................
Print name……………………………………. Date…………………………………………….
Parent Guardian (with parental consent)
Signature………………………………………
Print name:………………………………………
Date…………………………………………….
Corps Officer’s Section
I am aware that the young person who has signed above wishes to attend Summer School 2013 Signed…………………………………..
Print name………………………………………
MEDICAL CONSENT FORM Please ensure this form is completed and returned with your application form. You/your child will not be admitted to this event without this signed & completed form.
YOUR DETAILS Surname of Delegate ……………………… First Name…………………………………... Address…………………………………………………………………………………………………... Phone number………………………………….
Date of Birth…………………………..…..
YOUR GP’S DETAILS GP’s Name…………………………………………….
Phone number..…………………….……
Address………………………………………………………………………………………………………
MEDICAL HISTORY Does your child/ do you suffer with any medical condition or psychiatric condition? YES
NO
If YES please give details…
I agree to me/my child being given the following medication (tick as appropriate):
Do you/your child have any of the following conditions? Please give any further details as required. Epilepsy
Paracetamol Ibuprofen Throat Lozenges Insect bite relief Plasters Antiseptic Cream Travel Sickness Tablets
Diabetes
Asthma
Anaphylactic allergic reaction to a given substance e.g. bee sting)
(potential
MEDICAL CONSENT FORM continued MEDICAL HISTORY continued… Is your child/ are you up to date with all childhood immunisations? If NO please give details… YES
NO
Date of last tetanus? Does your child/do you have allergies to anything (e.g. medicine, stings, nuts, etc or have any phobias or fears that it may be helpful for leaders to be aware of? If YES please give details… YES
NO
Does your child/do you have any special dietary requirements? If YES please give details… YES
NO
Is your child/are you receiving any medical or psychiatric treatment at present? If YES please give details… YES
NO
Please give details of two people who should be contacted in case of an emergency: Name:
Name:
Relationship:
Relationship:
Address:
Address:
Phone No:
Phone No:
MEDICAL CONSENT FORM continued If emergency medical treatment is needed, do you give consent for this to be carried out according to the best judgement of any medical staff who may attend to your child/you? I give my consent for emergency treatment to be given if necessary. Parent/Carer
Delegate
(only needed if delegate is under 18 yrs)
Signed:
Signed:
Print Name:
Print Name:
I give consent for emergency anaesthetic to be given if necessary: Parent/Carer
Delegate
(only needed if delegate is under 18 yrs)
Signed:
Signed:
Print Name:
Print Name:
Please indicate whether you have parental responsibility for the child named on this form (only needed if delegate is under 18 yrs): Yes
No
The Salvation Army will use your/your child’s information for providing services and will process sensitive data accordingly. By signing this form you consent to us keeping such records on file during and for a period of 6 months after the event, and using them for the above purposes. The information will be stored securely and confidentially at DHQ/THQ. You have a right to ask for a copy of the information and to correct any inaccuracies.
MEDICAL CONSENT FORM continued
This section needs to be filled out by the parent/ carer of any delegate under 16 years old. UNDER 16s
Is your child taking any prescribed medication that will need to be administered during the event? Yes
No
Would you like us to administer that medication? Yes
No
If YES, please ensure that this section is completed as consent for us to administer medicine to your child on your behalf: Name of medication as described on the container:
What is it for?
For how long will your child need this medication?
Date dispensed: Expiry date:
Full directions for use and storage:
Dosage and method of administration (by mouth, inhaled, etc.)
Times to be taken:
Special precautions:
Side effects:
Procedures to be taken in an emergency:
If you would prefer us NOT to administer medicine to your child then please ensure that your child’s medication is stored safely (preferably in a locked container) and cannot be taken by other children.