WAALHIIBE Events
WAALHIIBE Registration Form
(All sections will expand on entry)
Event Information
Event name
RAW Camp
Event date
11-13 April 2014
Cost of event
$20
Payment due
Tuesday 1 April 2014
Payment options
Cash
Credit card
details
Credit card holder’s
Signature
Participant Information
Family name
Given names
Date of birth
Contact number
Email
Residential address
Educational Institution Information
University
Course and year
Emergency contact
Family name
Given names
Contact number
Email
Residential address
Relationship
Pay at reception:
Rural Health West, Level 2, 10 Stirling Highway, Nedlands
Expiry date
WAALHIIBE Events
If you are under 18 years of age please also complete the following guardian details.
Parent / Guardian / Next of Kin Information
Family name
Given names
Contact number
Email
Residential address
WAALHIIBE Events
Medical Information Form
This form is to assist Rural Health West staff in the event of a medical emergency.
Private health details
Medicare number
Private health insurance fund
Private health insurance fund number
General practitioner information
Name
Telephone number
Address
Do you presently have ANY condition or physical disability or current injury which
may prevent full involvement in the trip?
If yes give details
Allergies
Are you allergic to any of the following:
Antibiotic
Yes
No
Details
Environmental
Yes
No
Details
Any foods
Yes
No
Details
Other drugs
Yes
No
Details
Any other allergies
Yes
No
Details
If you said yes to any of the allergies please provide full details:
YES
NO
WAALHIIBE Events
Do you suffer from any of the following conditions:
Diabetes
Asthma
Heat Exhaustion
Dizzy Spells
Fits of any type
Lung complaint
Migraine
Heart Complaint
Sleepwalking
Epilepsy
Travel Sickness
Blackouts
If you said yes to any of the above please provide full details:
Immunisation
Have you been immunised against the following:
Immunisation
Date
Immunisation
Tetanus
Hepatitis A
Diphtheria
Hepatitis B
Whooping Cough
Hepatitis C
Polio
Typhoid
Measles
Meningococcal C
Mumps
Yellow Fever
Rubella
Other:
Date
Participant Name:
If I should suffer an injury or illness during the period of a WAALHIIBE event, I authorise the event
coordination staff to administer first aid to me or to use their discretion to transport, or to have me
transported, to any medical facility for treatment. I accept responsibility for any cost that may be
incurred.
I accept
Yes
No
Please enter your name, date and sign below before returning.
Participant’s given name
Participant’s surname
Signature
Date
Name of parent or guardian if under 18 years of age
Signature
Date
Please save this document and email to Sarah Carlin waalhiibe@ruralhealthwest.com.au