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Register for one of our programs

Places are limited for our programs, and we encourage you to email us or give us a call to discuss your requirements before completing this Program Application Form

Choose the program

Program Type *

Case Worker / Guardian Details

Case Worker / Guardian Name *

First

Last

Case Worker / Guardian Phone Number *

Case Worker / Guardian Email *

About the Participant

Participant Name *

First

Last

Date of Birth *

Address *

City *

State *

Postcode *

School Grade *

Participant Medicare Number *

Medicare Individual Reference Number *

Medicare Expiry Date *

Does the Participant identify as Aboriginal or Torres Strait Islander? *

Parent / Carer Name *

First

Last

Address (if different from above)

Mobile Number *

Email *

Emergency Contact Name *

First

Last

Relationship to Participant *

Contact Number *

Health Conditions and Medical Details

Please list any Health Conditions *

Attention Deficit Hyperactivity Disorder (ADHD)
Oppositional Defiant Disorder (ODD)
Anxiety
Asthma
Autism (Including Asperger's Syndrome)
Obsessive-compulsive Disorder (OCD)
Intellectual Disability
Speech Disability
Depression
Diabetes
Dyslexia
Post-Traumatic Stress Disorder (PTSD)
Anaphylaxis- Please provide detail below
Food Allergy- Please provide detail below
Other- Please specify below
None of the above

Additional information about Health Conditions including details of medications/dosage requirements.

Consent and information to help us

I consent to Boys To The Bush Inc. taking photos and/or video footage of the Participant whilst on the camp. *

Yes
No

I consent to Boys To The Bush Inc. using these images and footage to be uploaded to a Photo Gallery on their website and/or Social Media Pages. *

Yes
No

In the event of illness/accident and/or injury, I hereby give consent for Boys To The Bush Inc. staff to perform First Aid. *

Yes
No

In the event of an emergency, I Consent to Boys To The Bush Ltd. staff calling an Ambulance should they deem it necessary for the Participant. I recognise that costs involved with Ambulance travel will be my responsibility. *

Yes
No

I give consent for Boys To The Bush Inc. staff to store and administer medication/dosages as specified. *

Yes
No

Please list any activities the Participant can NOT take part in.

Please list any issues / behaviours / triggers etc that the camp staff should be made aware of. *

Please list any strategies you have to deal with these issues

I have read and agree to all Camp Terms and Conditions (The link to the Terms and Conditions are found on the footer on each page). *

Yes
No

Comment

© 2021 Boys to the Bush. Big Agency
Terms and Conditions
Staff Forms
Boys to the Bush recognises the Aboriginal and Torres Strait Islander Peoples as the true custodians of the land in which we live, work and play.