“Camp Diabetes”
Queensland Health – Making a difference for kids with Diabetes
www.campdiabetes.com.au
Dear Parent,
Thank you for your interest in Camp Diabetes.
relevant information about this Jelly Beans camp.
We have pleasure in setting out below
Date:
Friday 29th July to Sunday 31st July, 2016. Campers arrive between
5.00 and 6.00 p.m. on Friday and leave after lunch on the Sunday)
Location:
The Queensland Camping and Conference Centre, Obi Obi Road,
Mapleton, Sunshine Coast Hinterland
Cost:
$350.00. This includes all meals, accommodation and activities for
one parent and one child. Extra adults and children over 5 years
are $175.00 each.
Closing Date:
1st July, 2016
Final Payment Due:
22th July, 2016 – Due to high demand for this camp we suggest
that you register you child immediately you receive these forms as numbers are limited
If you wish to attend this camp you need to:
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Complete the registration kit
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Payment by cheque or money order made out to – SCHF-Camp Diabetes
Attach either full payment of $300.00 for one parent and one child, OR deposit of $50.00 (fully
refundable)
Return all documents to :
Camp Diabetes
Diabetes Resource Centre,
Gold Coast University Hospital
1 Hospital Blvd,
Southport 4215
A reply paid envelope is included for your convenience
On receipt of your documentation we will allocate a place for your child at camp. Closer to the
camp date, we will forward the relevant paperwork regarding what to bring, camp map, arrival
time and receipt.
If you require further information about either registering for Camp Diabetes or the camp itself,
please do not hesitate to contact Julie (0414 298004)
We look forward to seeing you at Camp Diabetes
Yours Sincerely,
Julie Pearson
Co-Ordinator – “Camp Diabetes”
Camp Diabetes ‘Jelly Beans’ Registration
CHILD DETAILS:
SURNAME
CHRISTIAN NAMES
PREFERRED NAME FOR BADGE
DATE OF BIRTH
ADDRESS
Male
Postcode
T.SHIRT SIZE
BRAND OF BLOOD GLUCOSE METER
PARENT/CARER DETAILS:
SURNAME
CHRISTIAN NAMES
RELATIONSHIP
PREFERRED BADGE NAME
ADDRESS IF DIFFERENT TO ABOVE
Postcode
EMAIL ADDRESS
PHONE NUMBERS
HOME
WORK
MOBILE
WORK
MOBILE
ADDITIONAL ADULT
SURNAME
CHRISTIAN NAMES
RELATIONSHIP
PREFERRED BADGE NAME
ADDRESS IF DIFFERENT TO ABOVE
Postcode
PHONE NUMBERS
HOME
ADDITIONAL ADULT
SURNAME
CHRISTIAN NAMES
RELATIONSHIP
PREFERRED BADGE NAME
ADDRESS IF DIFFERENT TO ABOVE
PHONE NUMBERS
HOME
Postcode
WORK
MOBILE
SIBLING DETAILS:
NAME
PREFERRED BADGE NAME
NAME
PREFERRED BADGE NAME
NAME
PREFERRED BADGE NAME
AGE
T.SHIRT SIZE
AGE
T. SHIRT SIZE
AGE
T. SHIRT SIZE
DIABETES HEATH CARE TEAM
DIABETES
SPECIALIST,
USUAL
DOCTOR OR DIABETES CLINIC
ADDRESS
Postcode
PHONE
Female
Other Medical Information
NAME
Does your child have Coeliac Disease
Does your child have any other
conditions such as Asthma, Epilepsy
etc.? If yes, please list
Does your child take any medication
other than insulin?
If yes, please list
AGE
Yes
No
Yes
No
1.
2.
3.
Yes
No
Usual Treatment
Has your child recently had or been in
contact with, any contagious diseases?
Yes
No
If yes, please give details
Does your child have any behavioural
problems
Yes
No
Is your child allergic to anything?
Allergic to:
Usual Symptoms
If so, what is the usual management?
Does your child have ADD or ADHD?
Does you child have an insulin pump
and what brand is it?
Yes
No
Yes
No
Brand: __________________________
Is there any further information that
we should know about your child?
Apart from the child with Diabetes,
does anyone else coming to camp have
any allergies, medical conditions or
require any special food that we should
be aware of?
Yes
No
If yes, please complete
information page
the
additional
Additional Information
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INDEMNITY FORM
To: Camp Diabetes
I/We the undersigned, request that you accept the application of ___________________
____________________________________________________________________
and/my child/children____________________________________________________
to attend Camp Diabetes Jelly Beans from Friday 29th July to Sunday 31st July 2016 at the
Queensland Camping and Conference Centre (QCCC) Mapleton, Queensland and in
consideration of you doing so, I agree to indemnify you and all officers and other
individuals, involved in conducting Camp Diabetes against all actions, suits, claims and
demands in respect of anything done or omitted to be done by those conducting this camp,
or in relation to journeying to and from camp and whilst on outing of any injury or illness
that may occur to either myself, spouse or child/children
I/we authorize you to obtain at your discretion all such medical assistance and treatment
for myself, my spouse/our child/children as you shall consider desirable and for this
purpose as my/our agent to engage ambulance services, doctors, nursing services and
hospital accommodation and I/we agree to pay to you on demand all charges imposed for
such ambulance services, doctors, nurses and hospital accommodation and associated
expenses.
Dated the____________day of ______________, 2016
Father’s Name and Signature______________________________________________
Mother’s Name and Signature_____________________________________________
Guardian/Carer Name and Signature________________________________________
Address______________________________________________________________
____________________________________________Postcode__________________
Should any act of misconduct by myself or any member of my party, whilst on camp give
cause for concern, I understand the Camp Co-Ordinator may discuss the possibility of
myself or members of my party, leaving the campsite.
I understand that any photographs and video film taken during the camp may be used for
promotional/educational use by Camp Diabetes, Roche Diagnostics and Diabetes Australia
and I hereby give permission for photographs or videos taken of my child/children to be
used for the promotion of Camp Diabetes in the future.
Signed_______________________________________Date__________________
Check List
These forms need to be returned:
1.
2.
3.
4.
Registration Form
Other medical information
Indemnity Form
Additional Information (if completed)
Payment for Camp
I have enclosed $................being:
deposit
or
full payment
for Camp Diabetes ‘Jelly Beans’ 29th July to 31st July 2016
Payment Form for Camp Diabetes
Payment for






Jelly Beans Camp
Jelly Beans Camp
Sleepover Camp
Week Long Camp
Young Guns Camp
Young Guns Camp
Payment by:



Cheque
Money order
Credit card
11 – 13 March 2016
29 July – 31 July 2016
29 April-1 May 2016
18 - 23 September 2016
17-19 June 2016
11-13 November 2016
If paying by credit card please complete the following.
Name: _______________________________________________________________
Address: _____________________________________________________________
_____________________________________________________________________
___________________________________State:______________Postcode:______
Phone: _________________ Email: ______________________________________
Payment by:  Credit Card  Cheque/Money order (Camp Diabetes)
Please charge ___________________ to my  Mastercard
 Visa
Card Number: _ _ _ _ / _ _ _ _ / _ _ _ _ / _ _ _ _ Expiry Date: _ _ / _ _
CCV No _ _ _ (found on the back of your credit card)
Cardholder’s name: ____________________________________________
Signature____________________________________
Please note : the payment will be taken by Wishlist, this will appear on
your bank statement
Please return to:
Julie Pearson
Diabetes Resource Centre
Gold Coast University Hospital
1 Hospital Blvd
Southport 4215
Fax: 07 56877626
Email: Julie.pearson@health.qld.gov.au