NOTES ABOUT THIS FORM Alphasys - Participant Registration FormForm ID 4733141All significant changes thru change process / recorded in change log. Follows are minor changes:29/08/19 - change default diet requ to No; change condition for anaph action plan to both severe and yes; change connector to skip attachment if blank Event ID Publish StatusPlease select... In Progress Published FORM ID 4733141 Adult Registration Fee Contact ID Registration AvailabilityPlease select... Register Waitlist Closed Concession Registration Fee Activity Instance ID Instance ID Filled?Please select... No Yes Concession Registration AvailablePlease select... Yes No Family Discount AvailablePlease select... Yes No Merchandise Available?Please select... Yes No Food IncludedPlease select... Yes No Event Specific Ques IncludedYesNo Additional Event Specific Ques IncludedYesNo NOT Catered for Special Dietary NeedsYesNo Payment Required?Please select... Yes No Payment in Full RequiredPlease select... Yes No Team Directors Email I am registering: Payment is mandatory to secure your registration for this eventPlease ensure that you have your credit card details on you before filling out this form as your application responses will not be submitted unless credit card details are provided. For event typePlease select... SU Camp SU School Group (ISCF, SUPA Club) SU Mission (SUFM, SUmmerlife) Other On behalf ofPlease select... Myself (aged 18 or over) My child (aged under 18) Someone else (aged under 18) Event name SU Activity Name Event Start Date Event End Date Event overnightTrueFalse Non-ResidentialTrueFalse Event overseasTrueFalse Expression of Interest Registrations are NOT currently open for this event, however if you would like to be notified when registatrations open, please fill out the form below. For event typePlease select... SU Camp SU School Group (ISCF, SUPA Club) SU Mission (SUFM, SUmmerlife) Other Event name SU Activity Name Contact Details First Name Last Name Date of birth Email Mobile phone Parent / guardian / carer's details First Name (Parent / Carer) One name only Last Name (Parent / Carer) Required field Email Required field Mobile phone (Parent / Carer) Address (Parent / Carer): Address line 1 Town / suburb StatePlease select... ACT NSW NT QLD SA TAS VIC WA Postcode Site / holiday address If applicable (eg in holiday park) Participant details This section can be replicated for each person being registered. Registration TypePlease select... Adult Concession AgePlease select... 18+ 16-17 11-15 6-10 1-5 <1 Registration Fee $ Concession Registration Fee $ First Name (participant) Last name (participant) Date of birth Age School name Year at school (next school term) Gender Please select... Female MaleRequired field Email (Participant) Required if over 18 otherwise optional Mobile phone (participant) What is your relationship with the child participant?Please select... Parent Guardian Case Worker Emergency contact name Contact Person during program Emergency contact phone Contact Number during program Relationship Emergency contact name (2) Contact Person during program Emergency contact phone Contact Number during program Relationship Participant's Address Is the participant's address the same as the above parent/guardian's address?Please select... Yes No Address (Participant) Town / suburb (Participant) State (Participant)Please select... ACT NSW NT QLD SA TAS VIC WA Post code (Participant) Medical Information Medicare Card No. Insurance Provider and Member No. Health Fund Details Current medications that participant is prescribed Details of last tetanus shot Is the participant currently on any prescribed medication?NoYes Medications that participant has recently stopped using Does paracetamol have to be adminstered to the participant? If yes, please give details. Does the participant have ambulance cover?Please select... Yes No Does the participant suffer from any of the following:AsthmaAnxietyEpilepsy / Fits / ConvulsionsBehavioural issues (Overnight events) Does the participant suffer from any of the following:AsthmaAnxietyBehavioural issuesEpilepsy / Fits / ConvulsionsSleep walkingHearing impairmentSight impairment Physical abilityPlease select... Normal function for age Limited function Advanced / athlete Reading levelPlease select... Normal for age Advanced for age Behind for age Swim abilityPlease select... Non swimmer Fair Swimmer - may need some assistance for more than 50m Good Swimmer - can swim more than 100m unassisted Typical Swimmer - can swim up to 100m unassisted Friends (under separate registrations) that the participant is attending with Are there any other things that we need to be aware of, particularly anything that might affect the health, safety or well being of the participant? (i.e. mental health challenges, previously fractured bones, etc) Event Specific Questions Q1. A1. Q2. A2. Q3. A3. Additional Event Specific Questions Q8. A8. Q9. A9. Q10. A10. Additional Event Questions Q4. A4. Q5. A5. Q6. A6. Q7. A7. T-shirt size e.g Ladies S Is anyone legally restricted from seeing the camper?Please select... Yes No Full name of the restricted person Registration Quantity Permission and Indemnity I permit my child / children to fully participate in all Scripture Union associated activities. In the case of a medical emergency I give permission to Scripture Union to attain medical assistance for my child / children. I understand that every effort will be made to contact me prior to initiating such. I permit my child to be transported as described in the information about the activity, or as otherwise may be required in emergency circumstances. Personal details will remain confidential and will not be provided to others except as may be required by Law.The Scripture Union privacy policy is available on our website www.sunsw.org.au. Please untick the below only if you DO NOT wish for your child to be photographed I grant Scripture Union permission to use photographs and video taken throughout this event of my child for news and promotional materials. Scripture Union may contact you by email or post occasionally throughout the year to let you know about future Scripture Union events. I would like to receive communications from Scripture Union. Total Registration Fee $ Total Registration Quantity Health & Dietary Requirements Does participant have any dietary requirements or allergies?Please select... No Yes Type of AllergyPlease select... Dairy Egg Fish Gluten Lactose Peanut Sesame Shellfish Soy Tree Nuts Wheat Other Other Severity LevelPlease select... Severe/Anaphylactic Significant/Sensitivity Intolerance Minor/Traces Acceptable Personal Preference Any special needs, health conditions, non-food allergies, etc Is there an anaphylaxis / allergic reaction action plan for any allergies listed? NoYes Upload anaphylaxis / allergic reaction action plan A reaction plan is required for those with severe allergies. An Epi Pen will need to be readily available. Merchandise Merchandise Item Quantity Unit Price Price $ Mens Polo Included?Please select... Yes No Mens Polo SizePlease select... M Quantity Price $ MP Resource ID Mens Polo SizePlease select... L Quantity Price $ Mens Polo SizePlease select... XL Quantity Price $ Mens Polo SizePlease select... 2XL Quantity Price $ Mens Polo SizePlease select... 3XL Quantity Price $ Mens Polo SizePlease select... 5XL Quantity Price $ Mens Polo Total Price $ Ladies Polo Ladies Polo SizePlease select... 8 Quantity Price $ Ladies Polo IncludedPlease select... Yes No Ladies Polo SizePlease select... 10 Quantity Price $ LP Resource ID Ladies Polo SizePlease select... 12 Quantity Price $ Ladies Polo SizePlease select... 14 Quantity Price $ Ladies Polo SizePlease select... 16 Quantity Price $ Ladies Polo SizePlease select... 18 Quantity Price $ Ladies Polo SizePlease select... 20 Quantity Price $ Ladies Polo Total Price $ Mens T-Shirt Mens T-Shirt SizePlease select... XS Quantity Price $ Mens T-Shirt Included?Please select... Yes No Mens T-Shirt SizePlease select... S Quantity Price $ MT Resource ID Mens T-Shirt SizePlease select... M Quantity Price $ Mens T-Shirt SizePlease select... L Quantity Price $ Mens T-Shirt SizePlease select... XL Quantity Price $ Mens T-Shirt SizePlease select... 2XL Quantity Price $ Mens T-Shirt SizePlease select... 3XL Quantity Price $ Mens T-Shirt Total Price $ Ladies T-Shirt Ladies T-Shirt SizePlease select... 6 Quantity Price $ Ladies T-Shirt IncludedPlease select... Yes No Ladies T-Shirt SizePlease select... 8 Quantity Price $ LT Resource ID Ladies T-Shirt SizePlease select... 10 Quantity Price $ Ladies T-Shirt SizePlease select... 12 Quantity Price $ Ladies T-Shirt SizePlease select... 14 Quantity Price $ Ladies T-Shirt SizePlease select... 16 Quantity Price $ Ladies T-Shirt SizePlease select... 18 Quantity Price $ Ladies T-Shirt SizePlease select... 20 Quantity Price $ Ladies T-Shirt Total Price $ Junior T-Shirt Juniors T-Shirt SizePlease select... 2 Quantity Price $ Juniors T-Shirt IncludedPlease select... Yes No Juniors T-Shirt SizePlease select... 4 Quantity Price $ JT Resource ID Juniors T-Shirt SizePlease select... 6 Quantity Price $ Juniors T-Shirt SizePlease select... 8 Quantity Price $ Juniors T-Shirt SizePlease select... 10 Quantity Price $ Juniors T-Shirt SizePlease select... 12 Quantity Price $ Juniors T-Shirt SizePlease select... 14 Quantity Price $ Juniors T-Shirt SizePlease select... 16 Quantity Price $ Juniors T-Shirt Total Price $ Other Clothing Items Please select... Cap - Snapback (Black) Quantity Price $ Snapback IncludedPlease select... Yes No Please select... Cap - Peak (Black) Quantity Price $ Peak IncludedPlease select... Yes No Please select... Hoodie Quantity Price $ Hoodie IncludedPlease select... Yes No Please select... Jumper Quantity Price $ Jumper IncludedPlease select... Yes No Please select... Beanie Quantity Price $ Beanie IncludedPlease select... Yes No Other Clothing Total Price $ Resources Please select... Aims, Beliefs, Working Principles Booklet Quantity Price $ ABWPB IncludedPlease select... Yes No Please select... Book Quantity Price $ Book IncludedPlease select... Yes No Please select... Ministry to the Interior Quantity Price $ MTTI IncludedPlease select... Yes No Please select... Childsafe Team Leader's Guide Quantity Price $ CTLG IncludedPlease select... Yes No Please select... Childsafe Team Member's Guide Quantity Price $ CTMG IncludedPlease select... Yes No Please select... Leader's Guide Quantity Price $ LG IncludedPlease select... Yes No Please select... Participant's Guide Quantity Price $ PG IncludedPlease select... Yes No Please select... Name Badge & Lanyard Quantity Price $ NBL IncludedPlease select... Yes No Please select... USB Flash Drive Quantity Price $ USB IncludedPlease select... Yes No Resources Total Price $ Other Items Please select... Water Bottle Quantity Price $ Water IncludedPlease select... Yes No Please select... Cup Quantity Price $ Cup IncludedPlease select... Yes No Please select... Other Quantity Price $ Other IncludedPlease select... Yes No Other Items Total Price $ Insurance Please select... Volunteer Insurance Quantity Price $ Ins IncldPlease select... Yes No Total Merchandise Cost $ Resources Merchandise Item Unit Price Quantity Price $ Total Price $ Select the Amount you would like to donate $20 $50 $100 $200 Other Enter the Amount you would like to donate $ Payment Summary Total Number of Registrants Family Member Discount % Discount Calc Total Registration Cost $ Total Merchandise Cost $ Total Donation $ Total Amount Payable $ Are you currently able to pay for this registration?Please select... Yes No Would you like to pay for this registration in full? Please select... Yes No If No, please enter the Amount you are able to pay for currently $ Remaining Payable in Future $ Payment Information Name on Card Card Number MM YY CVV Billing Email Charge ID Contact Information
