Virtual Camp Application (HGP / LTS) Virtual Program Application - Step 1 & 2 & 3 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. TitlePlease select oneMr.Mrs.Dr.Ms.MissName* First Name Last Name Relationship to Camper*Please select oneMotherFatherBrotherSisterGrandmotherGrandfatherStepmotherStepfatherAdoptive MotherAdoptive FatherFoster MotherFoster FatherAuntyUncleCase WorkerOtherOther Relation Address* Street Address Suburb State Post Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Mobile*PhoneEmail* Emergency Contact DetailsName* First Last Emergency contact Relationship to Camper*MotherFatherBrotherSisterGrandmotherGrandfatherStepmotherStepfatherAdoptive MotherAdoptive FatherFoster MotherFoster FatherAuntyUncleOtherOther type Relationship for Emergency Contact Emergency Contact Primary Contact Number* Emergency Contact Secondary Contact Number* Emergency Contact Email* Family Doctors InformationDoctor's Name* Doctor's Contact Number* Consent to contact Doctor*YesNoFrom time to time our Head Psychologist may need to consult with your child's Doctor.Bereavement 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 deathAlcohol Related Liver DiseaseAlzheimer’S DiseaseAppendicitisAsthmaBirth DefectCancerCardiovascular DiseaseChildbirthCirrhosisComplication Of SurgeryDementiaDiabetesDrowningEmphysemaFluHeart AttackHomicideInjuryMultiple SclerosisPneumoniaPoisoningRespiratory DiseaseSepsisStrokeSuicideTraffic CollisionVirusWorkplace AccidentOtherCause of death other Does your child know that their loved one died by suicide?YesNoWhere did this person dieAccident sceneCrime sceneHospitalHospiceHomeWorkOtherAdditional details surrounding deathHas the family received counselling?*YesNoHas the family received counselling? (If yes, please elaborate)