RYLA 2017 Application Form District 9455

Transcription

1 Participant Personal Details Surname: * Given Names: * Name for Badge: Gender: Date of Birth: / / Age at camp start: Address: Postcode: Home Phone: ( ) Mobile No.: * Preferred Number (Please circle): * Home Phone / Mobile No. Rotary Club Details (If Sponsored by Rotary Club) Sponsored by the Rotary Club of: * Rotary Club Contact Name: * Phone No: Occupation / Study Details Current Occupation / Studies: Employer / Educational Institute: Employer Contact Details (If sponsored by Employer) Employer Contact Name: *

2 Work Phone: * Additional Participant Details Interests (Please list any sporting interests, recreational pursuits, hobbies or club memberships.) Current Fitness Level (Please circle) * Low Moderate (Walk regularly) High (Run / play regular sport) What is your motivation for attending RYLA 2017? (Continue on the back, if needed) * Have you attended any other leadership programs? (Please circle) Yes No If yes, please specify Next of Kin Details Name: Relationship: Address: Postcode: Home Phone: ( ) Mobile No.: Preferred Number (Please Circle): Home Phone / Mobile No.

3 Medical Insurance Details Medical Practitioner (if applicable): Contact No.: Do you have private health insurance? (Please circle) Yes No Insurance Fund: Membership No.: Medicare No.: Blood Group (if known) Participant Medical Details Have you had a tetanus booster in the past 12 months? (Please circle) Yes No Unsure Can you swim 50m or more? (Please circle) Yes No Do you have any dietary requirements? (Please circle) Yes No If yes, please specify: Do you have a First Aid Qualification? (Please circle) Yes No If yes, please specify: Participant Medical Conditions Condition Please circle Details (If yes, please specify) Heart Problems Yes No HIV/AIDS, Hep C etc Yes No Respiratory Problems Asthma Yes No Other Yes No Allergies Food Yes No Drugs Yes No Other Yes No Diabetes Yes No Epilepsy Yes No Phobias Yes No Recent Illness / Operations Yes No Recent Breaks / Fractures Yes No

4 Other (Please specify): Medication (Please specify medicine, dosage and frequency)

5 Authority Declaration I certify to the accuracy of the information contained within this application. I further agree to attending and participating in all excursions, outings and activities that will occur over the natural course of RYLA I understand that all reasonable measures will be taken to ensure care and supervision and agree to indemnify the staff, organisers, my employer, my sponsor club, Rotary International and its officers against any claim arising from my participation in the course. I agree to follow any and all directions of the course staff and agree that failure to observe any reasonable rules or direction given by Directing Staff may result in the termination of my attendance and my intermediate notification of such action. In the event of accident or illness, I authorise any and all medical or dental assistance that may be rendered, including blood transfusions, as may be required. I further agree to meet all reasonable hospital, medical, nursing or ambulance fees incurred. I understand that this is a drug free event and I will refrain from smoking, drinking alcohol or taking illicit drugs during the period in which I am a participant. Talent Release Form I hereby give approval for images of me to be used by RYLA for publishing and/or promotional purposes relating to RYLA for five years from this date and indefinitely for archival and historical purposes. I understand that RYLA will not use images of me in an inappropriate manner, and that images of me will not be used for other purposes without my prior approval. Signature: Date: / / Return Address and Contact Details Name: RYLA committee Address: PO Box 91 Leederville WA RYLA.9455@outlook.com Mobile: Contact person Regan: or Tania:

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