Deafhood Camp RSVP Form

My Details

Your First Name *

Your Last Name *

Email Address *

Phone Number *

I am the main contact for my child(ren)

Main Contact

Full Name

Phone Number

Email

Attendees

Attendee 1

Attendee 1 Full Name *

Attendee 1 Age *

Attendee 1 Gender *

Confident Swimmer

Attendee 1 Medical Conditions/Allergies *

Attendee 1 Dietary Requirements *

Attendee 2

Attendee 2 Full Name

Attendee 2 Age

Attendee 2 Gender

Attendee 2 Confident Swimmer

Attendee 2 Medical Conditions/Allergies

Attendee 2 Dietary Requirements

Emergency Contact

Full Name *

Phone Number

Email

Medical

Please note that you will be responsible for labeling medication for your child(ren).

Please list medication(s) including reason for medication, dosage, frequency, and any notes.

Please select which medications your child(ren) may be given *

PanadolAsprinIbuprofenBenadryl

Are there any activities which are limited/discouraged by your child(ren)'s doctor? *

Any specific needs or accommodations required? *

Do your child(ren) have Asthma? *

YesNo

If yes, we will email you an additional Asthma action plan to fill out.

Parent/Guardian Consent *

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This health history is correct so far as I know. The person herein described has permission to engage in all activities as noted. I hereby give permission to the First-Aider or Adult-In-Charge to provide routine health care and witness prescribed medications. I consent for my child to receive such medical treatments as deemed necessary in the event of an emergency and to assume liability for any medical expenses involved. This authorisation extends to my child’s participation in any activity run by the Camp (except those limited as described above). Should a medical emergency arise during, I understand that reasonable efforts will be made to contact me or my delegated emergency contacts at the phone numbers I have provided. If it is believed that my child’s life or health may be adversely affected by the delay that an attempt to contact me or my designated alternate would cause, I consent to the administration of medical treatment and/or surgical procedures deemed necessary by the medical doctor and/or medical faculty and the immediate administration of life-sustaining measures deemed necessary under the circumstances.

Transport

All attendees must meet the group at the following address:

Adelaide High School, West Terrace, Adelaide SA 5000

Transport Option *

I will drive my child(ren) to Adelaide High School and pick them up.I will require a support worker to bring my child(ren) to and from Adelaide High School (additional fee)

Please list the names of people authorised to pick your child(ren) up after the camp *

Please list the names of anyone NOT authorised to pick your child(ren) up after the camp *

Fees

Please acknowledge that the maximum price for this camp may be up to $1,500 per family, depending on numbers and availability of grants and sponsorships. If your child(ren) have a NDIS plan that may cover this camp, please email Kiara at kiara@deafbutterflyeffect.com.au

Please also acknowledge that The Deaf Butterfly Effect has a 2 business days cancellation policy. If your child/ren need to cancel, please let us know during our business hours (Mondays - Fridays 9am to 5pm - not including public holidays).

NDIS Plan Holder Name *

NDIS Plan Holder Number *

Plan Manager Email *

Agreement

We will provide three supervising staff to attend the camp. They will be on hand to take all reasonable care to protect the participants and supervise their behaviour during the camp.

Parents/guardians/caregivers should be aware that supervising staff at The Deaf Butterfly Effect will not be responsible for any injury or damage to property which may occur at the camp, where staff members have not been negligent. All participants will be expected to abide by all camp rules and regulations, and to participate in a mature, cooperative, and responsible manner. If the participant needs specialised support, please contact Kiara and further arrangements can be discussed.

All camp participants are required to conduct themselves according to the following standards of behaviour. This Code of Conduct is to ensure the safety and well-being of all participants and applies to all participants as well as their parents/guardians.

Guiding Principles:

To ensure that the rights of all individuals are protected while attending the program
To establish the safest and best possible learning environment for all participants

Expectations:

Respect and adhere to program/activity rules and guidelines.
Act in a courteous manner and treat other participants, parents, volunteers, staff, and others with respect.
Appropriate language and behaviour are expected at all times.
Follow all instructions and directives given by program Staff.
Obey The Deaf Butterfly Effect and Narnu Camp’s policies and local, state, and federal laws.

Behaviour not permitted:

Improper language, e.g., profanity
Destruction of property
Possession or consumption of alcohol and illegal drugs, including the use of tobacco
Possession or use of harmful objects (i.e. firearms, weapons, knives)
The stealing of personal, program, or other property is prohibited.
Destruction of property
Violation of established curfew, when applicable
Disrespect of adults, other participants, volunteers, staff and/or those in leadership positions
Bullying, belittling others/putting down and being disrespectful of individuals’ differences
Aggressive physical behaviour
Leaving program space or boundaries without permission
Unchaperoned activity on site without proper permission and supervision
Behaviour that is deemed distracting or disruptive to The Deaf Butterfly Effect and Narnu Camp’s operations
Unacceptable, irresponsible, or inappropriate use of technology
Other conduct determined to be inappropriate.

This list of infractions is not all-inclusive. Program staff reserve the right to ask any participant to leave the program at any time. Participants who fail to adhere to this Code of Conduct are subject to a range of disciplinary actions.

When appropriate, immediate corrective action will be taken to ensure the safety and welfare of all participants. Failing to adhere to this Code of Conduct may subject participants to disciplinary action, without refund of camp fee, up to and including removal from the program/activity and future programs/activities offered at The Deaf Butterfly Effect.

I have voluntarily chosen to participate in this approved Deafhood Camp at facilities owned and/or operated by Narnu Camp

I acknowledge and accept that the camp may involve certain conditions, hazards, and risks, including injury or death or damage to property, and that The Deaf Butterfly Effect cannot control these risks.
I acknowledge there may be physically strenuous activities and certify that I am fit and physically and mentally capable of participation in all activities provided by the camp.
I have disclosed any and all medical conditions that could impact my own safety, or the safety of others.
I understand that I am giving the camp staff permission to administer all required medication to my child when needed.
In consideration of The Deaf Butterfly Effect providing the opportunity for me to participate in this camp, I release The Deaf Butterfly Effect, its Directors, camp coordinator, employees, and representatives from any and all liability to me, my parents and/or legal guardians, our personal representatives, estate, heirs, and assigns for any and all claims, demands and causes of action for any and all illness or injury to me, including death, and property damage arising out of, during or in any way connected with this camp.
I agree to indemnify and hold harmless, waive and covenant not to sue The Deaf Butterfly Effect, its directors, camp coordinator, employees, and representatives from any liability for the injury or death of any person(s) or damage to property that may result from my negligent or intentional act or omission while participating in the camp.
I hereby authorise the staff of this camp to act for me according to their best judgment in any emergency requiring medical attention.
I authorise and give consent for The Deaf Butterfly Effect to administer general first aid for any minor injuries or illnesses experienced by me during camp participation.
If I need emergency medical care and The Deaf Butterfly Effect is not able to reach my parent or the emergency contact, I authorise The Deaf Butterfly Effect to sign all necessary papers and arrange for emergency treatment and hospital care. I understand that The Deaf Butterfly Effect is not responsible for any medical expenses associated with any personal injury I may sustain and understand that The Deaf Butterfly Effect does not provide medical insurance for me.

I accept this agreement *

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