Teen Expedition – WA Simple Events

Attendee Details

First Name

Last Name

Email

Phone

Date of Birth

Age at Event Date

Gender

Pathfinder Club

Are you attending Teen Expedition as part of your Green Beret requirements?

Yes

No

I understand that as I am not working towards my Green Beret my name will be added to a waitlist and I will be notified on 15 September if an Expedition space is available for me. Fee payment will be required once notification is sent regarding an available space. The fee amount will correspond with the time the application was submitted – if by 31 August the fee will be $250, if after 31 August the fee will be $300.

Yes

No

Parent/Guardian Details

Parent/Guardian #1

First Name

Last Name

Email

Phone

Relationship to Attendee

Add another parent/guardian

Yes

No

Parent/Guardian #2

First Name

Last Name

Email

Phone

Relationship to Attendee

Primary Emergency Contact

First Name

Last Name

Phone

Relationship to Attendee

Secondary Emergency Contact

First Name

Last Name

Phone

Relationship to Attendee

Health Record

Please complete your medical and emergency details below.

All information is stored securely and accessed only by authorised personnel (i.e. event leaders, first aiders).

For event safety, it is vital that the information is up to date when the event begins. If you have any questions or would like to update the medical information you provide, please do not hesitate to contact us at wayouth@adventist.org.au

General

Medicare Number

Position on Medicare Card

Do you have ambulance cover?

Ambulance Cover Provider

Do you have private health insurance?

Private Health Insurance Provider

Private Health Insurance Member Number

Do you object to transfusions?

Date of last tetanus vaccination

Any non-medical dietary requirements?

Please advise any other non-medical dietary requirements

Medical Conditions

Please list below any known medical conditions or care notes, including:
allergies (anaphylactic), allergies (non-anaphylactic), anorexia/ eating disorders, asthma, autism, bed-wetting, blackouts/ dizziness/ fainting, bleeding disorder, diabetes, disability, eczema/ skin condition, epilepsy/ seizures, hearing impairment, heart condition, joint/ muscle/ bone problems, migraines, operations, phobia, recent illness, sleep walking, sight impairment, travel sickness, mental health issue. heart problems, respiratory problems, travel sickness, any other medical issue or care note.
Please email all action plans (i.e. anaphylaxis, asthma, diabetes) to wayouth@adventist.org.au

Add medical condition/care note

Medical Condition/Care Note 1

Symptoms

Triggers

Medication

Care Instructions

Add another medical condition/care note

Medical Condition/Care Note 2

Symptoms

Triggers

Medication

Care Instructions

Add another medical condition/care note

Medical Condition/Care Note 3

Symptoms

Triggers

Medication

Care Instructions

Medical Contact (Optional)

Add doctor’s details

Doctor’s Name

Practice Name

Phone Number

Non-Prescription Medication

Should my child feel unwell, I give permission for the Teen Expedition staff to provide:

Paracetamol

Yes

No

Ibuprofen

Yes

No

Anti-Histamine

Yes

No

Payment & Form Submission

Attendee

Price: $250

No payment items has been selected yet

Pay with Card (Stripe)

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