MDWA Camper Registration form

2nd - 4th October, 2019

The camp registration form is to only be completed by parents who have applied via email to the MDWA Camp Coordinator.

Please fill in this form and submit by September 5, 2019. It will automatically be sent to our Camp Coordinator, who will be in touch. If you need further information, please call Brooke on 0402 563 833 or 9380 3400.

Please complete the form below

Name *
Date of Birth *
Date of Birth
Name *
Emergency Contact Name 1 *
Emergency Contact Name 1
Emergency Contact Name 2 *
Emergency Contact Name 2
Will you be bringing your own support worker to camp, even if only during the days? *
Does the camper have any of the following? (please tick as many as apply) *
Is the camper taking any prescribed medications? *
Is the camper currently taking any non-prescribed medications? *
I give permission for Muscular Dystrophy WA's First Aid Officer to administer the following medication as required:
Please ensure you provide us with accurate information relating to the camper's equipment needs, to enable us to maximise the safety and comfort of both campers and staff.
Muscular Dystrophy WA will provide the following equipment on camp: • FULLY ADJUSTABLE ELECTRIC BEDS: with rails and pressure care mattresses (for campers who are non-ambulant) • HOISTS: these are with a T-bar attachment and take loop style slings • SLINGS: some loop style slings will be available, although we recommend that campers bring their own to ensure a more comfortable transfer process
Please indicate the camper's current level of mobility by ticking the relevant boxes
If the camper regularly takes a nutritional supplement, please ensure enough is brought with them.
1. Movies
During downtime at camp there may be an opportunity to watch some movies. As the campers attending are all of different ages, it is important to gain permission from parents of children under 18 years to watch movies of various ratings. Any movie nights or days will be supervised by staff and all chosen movies will be carefully selected and audience-appropriate. Please note: campers, carers, or family members will NOT be permitted to bring any MA15+ rated movies or R rated movies to camp.
2. Camp Activities *
Camp staff will go to all lengths to ensure camp-based activities are carried out safely. However, all activities carry an element of risk. I give permission for the camper to participate in supervised activities at Ern Halliday Recreation Camp as part of the MDWA School Holiday Camp, if scheduled in the camp itinerary.
Although we hope it will never be required, the complexities of certain types of muscular dystrophy and allied conditions create the need for a Hospital Emergency Plan to be in place for each camper so that the camp coordinator, paramedics and support staff know exactly how to coordinate the care of your child, should an emergency occur.
Please provide details of the camper's GP and any specialists regularly involved in their care:
Medicare and Private Health Insurance details:
PLEASE NOTE: in the event of an MDWA-determined emergency, an ambulance will be called regardless of a family's health insurance or ambulance cover, or our ability to reach an emergency contact.
By ticking this box and submitting this form, I declare that the answers I have given in this application and the documents I will provide are true and correct to the best of my knowledge and belief. I declare that I have read and understood all information provided and requested in this application. *