Camper Application – Step 1 Camper Application - Step 1 & 2 & 3 "*" indicates required fields Hiddenprebooking_hidden HiddenHave Bereavement details already Yes No HiddenHaveDoctorsinformation Yes No I declare that the information provided by me on this application is true and accurate to the best of my knowledge and belief. I understand that misrepresentation or incorrect information provided may result in refusal of application or revocation of acceptance.* I understand and agree with the above statement and will complete this application according to these terms and conditions. What type of camp are you applying for?* Face to Face Camps only (Family Day Camps) Virtual Camps only (Healthy Grieving program and Let's talk Suicide) Both types of camps This just determines the types of questions we will ask you relating to our programsName* First Name Last Name Relationship to Camper*Please select oneMotherFatherBrotherSisterGrandmotherGrandfatherStepmotherStepfatherAdoptive MotherAdoptive FatherFoster MotherFoster FatherAuntyUncleCase WorkerOtherOther Relation Are there any current court orders including parenting orders that we need to be aware of?* Yes No Please provide information regarding current court ordersHiddenApplying for Camp Location ACT Sydney Victoria Hunter Valley NSW HiddenCamp Date Applying For*Please select oneCamp Magic ACT 29th April - 1st May 2022Camp Magic Hunter 17th-19th June 2022Camp Magic Sydney 26th - 28th August 2022Camp Magic Sydney 9th -11th December 2022Address* Street Address Suburb State Post Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Mobile*HiddenPhoneEmail* Where do you work?* What position do you hold?* Emergency Contact DetailsName First Name Last Name Relationship to Camper*MotherFatherBrotherSisterGrandmotherGrandfatherStepmotherStepfatherAdoptive MotherAdoptive FatherFoster MotherFoster FatherAuntyUncleOtherOther Relationship Primary Contact Number*Email Family Doctors InformationDoctor's Name Doctor's Contact NumberConsent to contact Doctor*YesNoBereavement HistoryName of deceased* Relationship to camper (s)*MotherFatherBrotherSisterGrandmotherGrandfatherStepmotherStepfatherAdoptive MotherAdoptive FatherFoster MotherFoster FatherAuntyUncleOtherOther relation Where did they work? What position did they hold? What date did the death occur* DD slash MM slash YYYY Cause of death*Alcohol Related Liver DiseaseAlzheimer’S DiseaseAppendicitisAsthmaBirth DefectCancerCardiovascular DiseaseChildbirthCirrhosisComplication Of SurgeryDementiaDiabetesDrowningEmphysemaFluHeart AttackHomicideInjuryMultiple SclerosisPneumoniaPoisoningRespiratory DiseaseSepsisStrokeSuicideTraffic CollisionVirusWorkplace AccidentOtherCause of death other information Where did this person die*Accident sceneCrime sceneHospitalHospiceHomeWorkOtherAdditional details surrounding death*Has the family received counselling?*YesNoHas the family received counselling? (If yes, please elaborate)
