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Horse Riding Week Camps
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Horse Riding Week Camps
If you are a human and are seeing this field, please leave it blank.
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are required
Entry Form for the Camp Dated:
*
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Phone
*
Male/Female & Age
*
Bringing Own Horse?
*
Yes
No
Horse's Name
MEDICAL CONTACTS
Mother's Full Name
Home Number
Work Number
Mobile Number
Father's Full Name
Home Number
Work Number
Mobile Number
ADDITIONAL EMERGENCY CONTACT
Name
Relationship to Rider
Home Number
Work Number
Mobile Number
Medicare Number
Name of Family Doctor
Contact Number
Please check if you have any of the following
Asthma
Diabetes
Fits of any type
Heart Condition
Dizzy Spells
Migranes
Blackouts
Uneven Pupils
Other
VEGETARIAN
Do you require a vegetarian option?
Yes
No
ALLERGIES
Do you suffer from any allergies?
Yes
No
If yes, please list name and severity of your allergy and any medication required
Name of Drug
Type of Food
Describe Reaction
Tetanus Immunisation
It is particularly important that people dealing with horses are immunised against tetanus. Tetanus is normally given at five years of age as Triple antigen or CDT and at fifteen years of age as ADT. Year of last tetanus immunisation
Medication
Is it necessary for your child to carry their own medication at all times?
Consent To Medical Attention
I authorize the instructor in charge to administer first aid and call an ambulance if necessary for the medical attention of my child. I agree to bear any cost thereby incurred
*
Yes
No
Ambulance Cover
Covered
Yes
No
Membership Number
Expiry
Private Health Insurance
Name of Company
Type of Cover
Contact Details
Contact Name
Contact Phone
Contact Email
Subject
Message
1. Please tick the appropriate box if your child suffers from the following:
Bed Wedding
Sleepwalking
Soiling
Seizures
Diabetes
Headaches
Vision Impairment
Hearing Loss
Dizzy Spells
Heart Condition
Blackouts
Hay fever
Asthma
Fears/Phobias
Other
If Yes, please give details:
2. Does your child have any chronic illness, medical condition, or physical restriction? YES / NO
3. Please tick the box which best describes your child’s ability to swim:
Excellent
Good
Poor
Non Swimmer
Further Comments:
4. Is this your child’s first trip away from home without you?
YES
NO
5. Please tick the appropriate box if you child has been diagnosed with any of the following:
Autism
Tourette ’s syndrome
ADHD
Intellectual Disability
Physical Disability
ODD
Mental Health Condition
Aspergers Syndrome
Other
If Yes, please provide a Behaviour Management Plan and further details:
6. Please tick the appropriate box if your child needs assistance with any of the following:
Bedtime
Toileting
Hygiene
Meal Times
Showering
Other
If Yes, please give details:
10. All prescribed medication is the be provided in a pharmacy issues Blister Pack, Webster Pack, or Dossette Box, that is clearly labeled. If your child is on medication, please list below:
Medication Name
Dosage - Before B/Fast
Dosage - B/Fast
Dosage - Other times
Dosage - Lunch
Dosage - Other times
Dosage - Dinner
Dosage - Other times
Dosage - Bedtime
Further Comments and Side Effects:
PARENT'S/GUARDIAN'S STATEMENT
PARENT'S/ GUARDIAN'S SIGNATURE
DATE