Student Application & Authorisation Form
APPLICATIONS CLOSE 15TH AUGUST 2014
Please send completed application forms to:
PO Box 604, Mount Hawthorn, WA, 6915 or
camp@zero2hero.com.au
Questions or queries to:
camp@zero2hero.com.au or Casey on 0433 430 087
What: Camp Hero is a youth leadership training camp hosting 25 to 50 of Western Australia’s most promising Year 8
to year 11 students. The camp is facilitated by WA-based not-for-profit organisation zero2hero.
Camp Hero aims to equip students with the skills required to become mental health leaders and ambassadors in their
community. The week long camp covers a wide range of topics: communication, leadership, self-awareness, health,
and nutrition, teamwork and overall wellbeing. Through tailored workshops Camp Hero develops young people to be
the best version of themselves and supports students in facing their fears, challenging themselves physically and
learning through games and entertainment.
Camp Hero is fully funded by zero2hero and therefore we are limited with the number of students we can
accept. The selected participants will be chosen based on their commitment to being a leader in their
community and particularly on their passion and desire to make a difference in the area of mental health.
The programme has been designed so that every student will take communication and leadership skills away from the
camp, and that they may in turn use these skills in their schools or communities to create positive change to increase
awareness around mental health, reduce the stigma associated with mental illness and prevent suicide.
Where: Camp Hero will be held at Forrest Edge Recreation Camp 90 minutes south of Perth just outside of Waroona.
The camp boarders beautiful State Forrest and is only minutes away from the Waroona Dam and Drakesbrook Wier.
When: The camp will be held from Monday 6th – Friday 10th October 2014.
Speakers and Mentors: There will be a variety of special guest speakers as well as supportive mentors to
accompany the students throughout the camp.
Transport: Bus transport will be provided to and from the camp free of charge for students. The pick-up and drop-off
location will be in the central Perth area. Upon acceptance more information will be provided.
Cost: Free.
What to Bring: Upon acceptance, an information kit will be sent to you listing all the items you will need to pack for
camp.
Safety: We take student safety extremely seriously. All volunteers require current police and working with children
checks. Risk and safety assessments are conducted prior to each activity. Speakers and volunteers will act in
accordance with zero2hero’s volunteer code of conduct at all times under the supervision of the zero2hero
management team. There will be qualified first aid and bronze medallion volunteers on-site for the duration of the
camp.
Application
All information will remain confidential and only shared with Camp Hero representatives.
Name: _________________________________________________ Nickname (if applicable):___________________
Age: _______________ D.O.B.:______/______/________ M/F: ____________________________ Grade: ________
School: _______________________________________________________________________________________
Shirt Size (S, M, L etc for Camp Hero T-Shirts):________________________________________________________
Special Dietary Requirements: _____________________________________________________________________
Parent/Guardian(s): _____________________________________________________________________________
Home Address: ____________________________________________________________ Post Code: ___________
Daytime Phone: ___________________________________ Evening Phone: ________________________________
Mobile Phone(s):________________________________________________________________________________
Email Address: ______________________________________ How often do you check email? _________________
How did you hear about Camp Hero? _______________________________________________________________
Tell us about YOU…
What are your top 3 strengths? ____________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
What are 3 of your weaknesses/limiters? ____________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
What are your hobbies, interests and passions? _______________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Which sports, school and community groups are you involved with? ________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
What do you consider your greatest achievements? ____________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Where do you see yourself in 10 years? _____________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Why would you like to come to Camp Hero? __________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
What kind of friend are you? _______________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
If you had one wish that could change the world, what would it be? ________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
If you were in charge of your school, how would you deal with bullying or mental health issues? __________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
We receive many application forms, why do you deserve a place on Camp Hero? _____________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
If you had a hero name, what would it be? Why? _______________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Interview
You may be required to attend a short interview to secure a place on Camp Hero. These will be held after 3.30pm on
Wednesday 3rd September at a northern location and Thursday 4th September at a southern location. Specific times
and locations will be confirmed once applications have been received. Please email camp@zero2hero.com.au if
you are not able to attend these dates.
Medical Information
Medicare No.:_________________________________ Private health cover: ________________________________
Usual GP: _____________________________________________________________________________________
Practice: ________________________________________________ Contact: ______________________________
Please indicate whether you experience any of the following:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Heart Problems
Respiratory Problems
Travel Sickness
Serious phobias
Operations
Recent Illnesses
Migraines
Blackouts
Fits, Epilepsy, etc.
yes
yes
yes
yes
yes
yes
yes
yes
yes
/
/
/
/
/
/
/
/
/
no
no
no
no
no
no
no
no
no
10.
11.
12.
13.
14.
15.
16.
17.
18.
Asthma
Diabetes
Restrictions on Activities
Special Diet
Disability
Medication Required
Drug Reactions
Allergies (i.e. beestings, etc.)
Difficulty swimming
yes
yes
yes
yes
yes
yes
yes
yes
yes
/
/
/
/
/
/
/
/
/
no
no
no
no
no
no
no
no
no
If you answered 'yes' to any of these questions, please specify:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Do you have any experience with mental illness? ______________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Are there any other issues that we should be aware of that may be relevant to your participation in the camp? If yes,
please specify:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Do you give permission for zero2hero staff to administer over the counter medication i.e. Panadol or anti histamine to
your child if required? yes / no
Authorisation
I declare that I have read the information regarding ‘Camp Hero' to be held from the 6th – 10th October 2014. I
understand that it is a condition of participation to accurately complete this form, including Medical Information.
In signing this document I am aware that I can freely elect to participate in camp activities and that any risk is
voluntary. I understand that if I have questions about possible hazards, it is my responsibility to seek additional
information from the camp staff prior to signing this form. I also understand that, despite safety precautions,
zero2hero, Forrest Edge Recreation Camp, and their staff or volunteers cannot guarantee that I will not be injured.
I understand that there may be risks involved for both myself and/or my property, and choose to participate based on
this understanding. The specific risks to myself vary from (1) minor injuries such as scratches, bruises and sprains, to
(2) major injuries such as eye injury or loss of sight, joint or back injuries, heart attacks, and concussions, to (3)
catastrophic injuries including paralysis and death. I understand that these risks may be the result of sporting games;
strenuous activities and quick movements in physical activities and the inherent risk to cardiovascular, muscular, and
skeletal systems. The specific risks to my property vary from (1) minor damage such as physical damage, to (2)
permanent damage such as completely destroyed and non-repairable. I agree to assume these risks. I agree to
accept the risk, and release to the full extent permitted by law, Forrest Edge Recreation Camp and zero2hero, from
the responsibility for any injuries which I may suffer or property damage as a result of my participation in the programs
and activities at ‘Camp Hero'.
In the event of accident or illness, I authorise the committee to arrange medical treatment and emergency evacuation
services, as the organisers deem necessary for my safety and well being. I authorise the committee to consent, where
it is impractical to communicate with me, for me to receive an x-ray, surgical or hospital treatment as may be deemed
necessary by a licensed physician and/or surgeon. I also authorise to engage in such treatment, and to pay the
appropriate fees for such and any other emergency transportation costs, which may be required. I agree to meet the
expense of me being returned home, by the committee accompanying me and then re-joining the group. I understand
that such an arrangement may be necessary due to illness, injury, or if, in the opinion of the committee, noncooperation of any description or the inability to meet the rigours and requirements of the activity. I agree to attend on
this understanding.
I understand that zero2hero does not provide any treatment or professional services for mental health issues, and that
anyone who thinks they may need treatment or professional services for mental health issues should contact
YouthFocus or another suitable provider.
I understand Forrest Edge Recreation Camp and zero2hero will not be held responsible for missing details such as
medical details.
I agree to the above statement.
Signature of Applicant ____________________________________________________________________________
Name of Parent: ___________________________________ Signature of Parent_____________________________
Photo Release Consent
I hereby consent to the use, for any lawful purpose, including but not limited to advertising, of my name, voice, and
any photographs or videos of me taken on behalf of zero2hero and reproductions of the same in any form, in any
medium, including on the World Wide Web, hereby releasing zero2hero from all liability arising from use of Images
including what I might deem misrepresentation of me by virtue of distortion, optical illusion or faulty mechanical
reproductions. I agree that all such images and videos of me, as well as all copyrights shall remain the property of
zero2hero.
I agree to the above statement.
Signature of Applicant ____________________________________________________________________________
Name of Parent: ___________________________________ Signature of Parent_____________________________