Registration Form

Duke of Edinburgh’s Five Day Residential Package

Wilderness First Aid Certificate

Plus Bush Survival Skills

Sunday 5th to Thursday 9th December 2010

$680.00 per person

Registration close one month prior

Maximum 20 participants, course will be postponed if numbers are not achieved

Please print then email, mail or fax to the address above.

PAYMENT OPTIONS:                                                            

□   $300.00 DEPOSIT on registration, with balance paid by arrival

□   Pay in full $680.00 per person

PAYMENT METHODS:

□ By cheque made out to ‘Laurel Hill Forest Lodge’

Mail to 1670 Batlow Road Tumbarumba 2653

□ By direct deposit Westpac Bank Details:

Laurel Hill Forest Lodge BSB 032 766 Account No.112395

Signature Student

Signature Parent/ Guardian                                                                   Date   

Medical Information Form

To be completed and sent with registration form.

Students name: ……………………………………………………………………………………………………………………………….

Medicare Number: ………………………………………………………………………………………………………………………….…

Parent or Caregiver contact details:

Name: …………………………………………………………………………………………………………………………………………..

Address: ……………………………………………………………………………………………………………………………………….

Home Phone: …………………Work: …………………Mobile: …………………………………………………………………………......

Emergency contact details: nominated by the parent or caregiver as alternate contact                                                                                                                                                              Name: …………………………………………………….............................…...........  Phone: ………………………………………… 

Name: ………………………………………………………….....................................  Phone: …………………………………………  

Family doctor contact details:

Name: …………………………………………………………………………………………………………………………………………...

Address: ……………………………………………………Phone……………………………………………………………………………

Health/ fitness aspects of the child that may require special attention, including existing medical conditions, illnesses or allergies.

Outline the treatment for each.

……………………………………………………………………………………………………………………………………………………

Are any medication(s) to be administered during the expeditions. Include name of medication, instructions for administration,

 time of administration, and any possible reactions.

……………………………………………………………………………………………………………………………………………………

Outline special dietary needs including possible reaction to inappropriate diet.

……………………………………………………………………………………………………………………………………………………

Furthermore I authorize any officer, member or servant of the Duke of Edinburgh’s award, in the event of any accident or illness

to obtain such urgent medical assistance or treatment for my son/daughter, including the administration of any anesthetic or blood

transfusion as he or she may consider expedient, and for this purpose to engage any first aiders, ambulance officers, doctors,

dentists, nursing assistance or hospital accommodation and hospital fees (other than fees and expenses recoverable by the

 Duke of Edinburgh Award under any policy of insurance.)

Signed: ……………………………………………………………….Date: …………………

Privacy Advice

The above information is being obtained in case medical assistance is required for your son or daughter over the course of the expedition.

Other persons and/or agencies that may be provided with this information are medical agencies such as ambulance officers,

nurse and doctors to enable appropriate first aid treatment by providing an accurate medical history of the patient.

Parent consent  FORM

Duke of Edinburgh’s Five Day Residential at Laurel Hill forest lodge

Students name: ………………………………………………..…………………………………………………………………………

Address: …………………………………………………………………………………………………………………………………...

I consent to my son/daughter attending the Hume and Hovell Duke of Edinburgh’s Award Residential program                                                    

from _____________________ to_____________________

I am aware that the students will not be supervised at all times during the residential program as part of their requirements

for their Gold Duke of Edinburgh’s Award.

I have arranged the major forms of transport to and from their home address to Laurel Hill.

I also consent to my son/daughter being transported at various times during  the residential program in vehicles driven by staff

from Laurel Hill Forest Lodge and WILD AID Outdoor Training staff.

Signed: ……………………………………………………………… 

                                Parent’s Signature

Date: ………………………….