applications close: 5pm friday 31 august, 2018 · phone: 03 8359 0143 mobile: 0408 454 156 email:...

Edmund Rice Camps (Victoria) Inc. – Spring Journey Camp 2018

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SpringJourneyCamp2018

ParticipantApplicationForm[offlineversion]

SpringJourneyCamp(12-15yearoldboys)–Monday24–Friday28thSeptember,2018

Applicationsclose:5pmFriday31August,2018

The Edmund Rice Spring Journey Camp is designed to provide an opportunity for youngmen to go on a'journey'thatisaimedatpromotingtheirsenseofselfworth,theirteamworkskills,theirdecision-makingskills and their ability to overcomedifficult situations.with the support of one youngadult volunteer perparticipant.Participantswillmakenewfriends,havefunandcreatelastingmemories.Thiscampincludessomehikingandstayingintentsfortwonights.Theone-to-oneratio,ofvolunteerstoparticipants,givestheyoungpeopleasafeandsupportivespacetothrive.EdmundRiceCampswelcomesparticipants fromallbackgrounds;ourvolunteersareable toworkwithavarietyofdifferentbehaviourspresentedbytheyoungpeople.Ifyou’reunsurewhetheryouclientwouldbesuitable,pleasecontacttheofficetodiscuss.

AllapplicationswillbecontactedbyFriday7September,2018.Successfulapplicantswillreceiveanacceptanceletter,anInvoice,a‘whattobring’listanddetailsofthepickupanddropofflocationforthecommencementandconclusionofcamp.

KeyInformation:1. Costofcampis$270perparticipant[Invoicewillbeissuedaftera

participantisaccepted]2. Pleaseensurethatallforms(PersonalDetails,Medical,Conditions

ofPlacement&DoxaConsentForm)arecompletedandsignedinfullbeforesubmitting.3. TheDoxaCampsiteConsentForm(Pages8and9)mustbecompleted.Thiswillbeprovidedtothe

DoxaCampsite.4. Allformsmustincludea24hourorAfterHourscontactforagencyreferrals.5. We’veincludedaStrengths&DifficultiesQuestionnaireonPage7.Thiswillhelpusbetterplacethe

participant.6. ApplicationswithaseparateSupportLetterfromthereferringagencywillbemorehighlyregarded.

Thesupportlettercancontain:• reasonsforreferral,• anygoalsfortheparticipantinattendingthecamp,• otherrelevantinformationtobeabletosupporttheparticipantduringthisplacementifsuccessful

Completingthisform.ThisofflineformcanbecompletedelectronicallyinMicrosoftWord.[online:http://www.ercvic.com/refer]Parent/Guardianmustsignpages4,5&7.Referrer/Agencyworkermustsignpage5.Submitviaemailtoprograms@ercvic.comorviaposttoEdmundRiceCamps,7AmberleyWay,LowerPlenty3093.IMPORTANT:AnaphylaxisManagementonEdmundRiceCamps

Whatisanaphylaxis?Anaphylaxisisasevereallergicreactiontoasubstance,mostcommonlynuts,egg,milk,wheat,soy,seafood,someinsectstingsandmedications.Itcanbelifethreatening,butwithpropermanagementandpreventionstrategiesinplacetheriskscanbesubstantiallyreduced.HasyourchildbeendiagnosedwithAnaphylaxis?Ifso,youmust:

1. MakesureyouletusknowontheMedicalPageofthisform2. HelpusputtogetheranERCIndividualAnaphylaxisManagementPlan3. SendincopiesofanASCIAactionplanforyourchild,withanup-to-datephotograph4. BringyourEpipen®(ensureithasnotexpired)

WetakeAnaphylaxisAllergiesveryseriously.EveryEdmundRiceCampProgramisentirelynutfree!Getmoreinformation:

ViewourfullAnaphylaxisPolicyhere:www.ercvic.com/publications.phpDEECDwebsiteatwww.education.vic.gov.au/anaphylaxisAnaphylaxisAustraliaInc,atwww.allergyfacts.org.au

Save Time Fill this form out Online

(www.ercvic.com/refer)


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PersonalDetails

Participantdetails:Fullname: Gender

Address: Suburb: PostCode

DateofBirth: AgeonCamp:

OptionalDetails:

Culturalbackground

WhatisthemainLanguagespokenathome?

DoesthechildidentifyasAboriginaland/orTorresStraitIslander? Yes No

Parent/GuardianDetails:Parent/Guardian’sname: Relationshiptoparticipant:

Address: Suburb: PostCode:

HomePhone: WorkPhone: MobilePhone:

NameofNextofKin: Relationshiptoparticipant:

HomePhone: WorkPhone: MobilePhone:

Preferencefordropoff&pickup:Pleasecircleoneoneachline

Dropoff(startofcamp) LowerElthamPark BrimbankPark(Keilor) Pickup(endofcamp) LowerElthamPark BrimbankPark(Keilor)

AgencyDetails:NameofReferringAgency: ContactPerson:

Address: Suburb: PostCode: AgencyPhone: AfterHoursContact: Afterhoursphone:

Email:

Funding:AnInvoicewillberaisedtothepersonoutlinedunder‘AgencyDetails’section.Ifyourequireaninvoiceraisedtosomeoneelse,pleaseprovidedetails:

HasthechildcompletedotherEdmundRiceCamp?Ifso,when?

PleaseNote:IfanafterhoursphonenumberisnotavailablefromthereferringagencypleasecallAdrianattheERCoffice

beforelodgingthisformtodiscussotherarrangements,otherwiseyourapplicationwillnotbeaccepted.

IfyouhaveanyquestionspleasecontactAdrianScerriattheERCofficeon–Phone:0383590143Mobile:0408454156Email:[email protected]

Alternativelyyoucanvisitourwebsitewww.ercvic.comOfficeUseOnlyDatabaseID Receiveddate Receivedmethod SupportLetter? Status Formenteredby Formentereddate DOXAform?


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Medical,PrivacyandPermissionThisformiscompiledtoassistEdmundRiceCampsstaffandvolunteersintheeventualityofanyillnessoraccident

oncampandwillbeheldoncamp.Pleasebeasspecificaspossibleinyourresponses.

CONFIDENTIAL

1.Participant’sName:

MedicareNo: Expiry: HealthCareCardNo: Expiry:

Doctor’sName: Doctor’sPhoneNo: DateoflastTetanusShot:

AmbulanceCover PrivateHealthInsurance–Provider: Number:

2.Dietaryrequirements:(i.e.vegetarian,vegan,glutenfree,Halaletc.)

3.Doestheparticipanthaveanyallergies?(i.e.Penicillin,SpecificFoods,FoodAdditives,Drugsetc.)

4a.HastheparticipantbeendiagnosedwithAnaphlaxis? Yes No

b.DoestheparticipanthaveanEpiPen? Yes NoIftheparticipanthasbeendiagnosedwithAnaphylaxis:

qHelpusputtogetheranERCIndividualAnaphylaxisManagementPlanqSendincopiesofanASCIAactionplanforyourchild,withanup-to-datephotographqBringyourEpipen®(ensureithasnotexpired)

5.HastheparticipantbeendiagnosedwithAsthma? None Mild SevereIfyourchild’sasthmaisdescribedasbeingsevere,anasthmamanagementplansignedbyaRegisteredMedicalPractitionermustbeprovidedwiththisapplicationalongwithdosageamountsandprescribedmedications.AsthmaManagementPlanAttached

Details:

6.Pleaseticktheappropriateboxiftheparticipantsuffersfromthefollowing:BedWetting Seizures DizzySpells SoilingTravelSickness Sleepwalking HearingLoss HayFeverHeadaches Diabetes HeartCondition Fears/PhobiasSightLoss BlackOuts Other None

Details:

7.Doestheparticipanthavechronicillness,medicalconditionorphysicalrestriction? Yes NoIfyes,pleasegivedetails: 8.Pleaseticktheappropriateboxiftheparticipanthasanyofthefollowingdisabilities:Autism Asperger’sSyndrome ADHD/ADDIntellectualDisability PhysicalDisability ODDMentalHealth/Illness Other None

IfYes,pleaseprovidefurtherdetailsofwhatassiststhem.AseparateBehaviourPlancanbeveryusefulinensuringwearemanagingtheparticipant’sbehavioursinaconsistentway.

9.Pleaseticktheappropriateboxiftheparticipantneedshelpwithanyofthebelow:Bedtime Toileting Hygiene MealTimes Showering Other None

Details:

10.Tohelpustailorthebikeridingandswimmingactivities,pleaseanswerthefollowingquestions:Height Lessthan100cm 100cm–119cm 120cm–134cm 135cm–149cm morethan150cmBikeridingability Neverriddenabike Poor Good ExcellentSwimmingability Nonswimmer Poor Good Excellent Furthercomments:


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12. All prescribed medication is to be stored in a Blister Pack or Dosette Box that is clearly labeled.Iftheparticipantisonmedicationpleaselistbelow:MedicationName Frequency & Time

ofdayDosage Comments

13.Arethereanyrecentorongoingsituationsatschoolorhomewhichmayhavesomeimpactonyourchildduringcamp? 14.Whatdoesyourchildlikedoing,whataretheirinterests? 15.Doesyourchildpresentwithanychallengingbehaviours?Ifso,what’sthebestwaytorespondtothese? DISCLAIMERSubjecttoanylawtothecontrary,andtothemaximumextentpermittedbylaw,EdmundRiceCampsInc.Victoriaanditsofficers,employeesandagentsdisclaimallliabilityforanylossordamage(whetherforeseeableornot)sufferedbyanypersonparticipatingonacampofferedbyEdmundRiceCampsInc.Victoriawhetherthelossordamagearisesinconnectionwithanynegligence,defaultor lackof careon thepartofEdmundRiceCamps Inc.Victoriaoranyof itsrepresentativesoranyothercause.PRIVACYDoesEdmundRiceCampsInc.Victoriahaveyourpermissiontoreproduceanyphotographs,videofootageand/oraudiorecordingstakenonthecampofyourchild,inanyofourpublicationsandwebsite,ontheunderstandingthatnonamesaretobeusedwithoutyourauthorisation? Photographs,Audio&Video Yes No

PERMISSIONTOATTENDANDMEDICALAUTHORITYI_______________________________________beingparent/guardianof_______________________________________dogivepermissionforhim/hertoengageandparticipateinthisEdmundRiceCampandtheactivitiesoffered.IfurtherauthorisethatanydulyauthorisedagentsofEdmundRiceCamps Inc in theeventofanyaccidentor illnessandwhere it isnotpossibleorreasonabletoobtainmyconsentatthetimetoengageanymedicalpractitionerorhospitalfacilitiesoraccommodationandinthiseventIagreetopayallsuchambulance,doctor,nurseorhospitalexpenses.IhavereadandIaccepttheaboveconditionsanddisclaimerrelatingtoparticipationinEdmundRiceCampsInc.VictoriaprogramsandIgivemypermissionformyson/daughtertotakepartinthem.Signed_______________________________________________________________________________________Date_______________________________(Parent/Guardian)

INCOMPLETEFORMSWILLNOTBEACCEPTED

Postformsto:EdmundRiceCamps,7AmberleyWay,LowerPlentyVIC3093

Emailformsto:AdrianScerri,[email protected]


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CONDITIONSOFPLACEMENT

PleasereadthefollowinginformationrelatingtocampsconductedbyEdmundRiceCampsVictoriaInc.Asignedcopy, signifying acceptance of these conditions and a belief on the Agency’s part that the participant(s) seekingplacementissuitedtoERCprograms,mustaccompanyeachapplicationforplacementonanEdmundRiceCamp.

1.EdmundRiceCampsarestaffedentirelybyvolunteers,principallyaged17to30.Whilevolunteerswithsomeprofessionalqualificationsholdexecutiveleadershiprolesoneachcamp,themajorityofleadersdonotholdsuchqualifications.

2.All information thatmayaffect thebehaviourof theparticipant(s)on thecamp, including their interactionwithleadersandotherparticipantswithintheagerangeofthecamp,mustbeforwardedwiththeapplication.

3.Transportoftheparticipant(s)toandfromthedesignatedpickupanddropoffpoint,atthecommencementandconclusionofthecamp,isnottheresponsibilityofEdmundRiceCamps.

AChildProtectionMatterisanyinformationrelatingtoachildunder18yearsofagepertainingtoanypastorcurrent,actualorsuspectedconcernforthatchild'ssafety,welfareorhealth.

4. If aChildProtectionMatter arisesoncamp,EdmundRiceCampswillmakecontactwith theAgencywiththedetails.ERCincollaborationwiththeAgencywillthendevelopaplantonotifyandsupportthechild and family, and to contact the Department of Health & Human Services where appropriate. TheAgencywillnotifyERCpriortothereleaseofthisinformationtothefamilyorcarerduringthecamp.

5.TheAgencywillnotifyEdmundRiceCampsofanyrelevantandongoingChildProtectionMatteraboutthechildpriortothebeginningofthecamp.Thisinformationwillbekeptinconfidence.

6.TheAgency’scontactphonenumber,bothduringbusinesshoursandafterhours,istobeprovidedwiththeapplication.ThisisimportantinthecasethataChildProtection,healthorbehaviouralissuearises.

7.Shouldaparticipant(s)needtobesenthomefromacamp,duetoillnessorinappropriatebehaviour,itistheresponsibilityoftheAgencytoprovidetransport.

8. The participant(s) seeking placement must fit the criteria of being either socially or economicallydisadvantaged.

9. Edmund Rice Camps Inc. reserves the right to accept or reject any application based on the best possiblematchbetweenapplicantsandtheskillsofthevolunteersonaparticularcamp.

10.ItistheresponsibilityoftheAgencytoensurethattheparticipanthasappropriateclothingandequipmentforthecamp.Ifextraclothingand/orequipmentareneeded,pleasecontacttheERCofficeforalternatives.

11.Theparticipant(s)maybeinvited to takepart inanoptionalevaluationof thecamp,all responseswillbeconfidential,theresponseswillbecollatedalongwithresponsesfromagenciesandvolunteersthende-identifiedtoevaluatetheentirecampanditsprocesses.EdmundRiceCampsInc.valuesallfeedbackreceived.ThepurposeoftheevaluationistoexpandontheresourcesandprogramsdeliveredbyEdmundRiceCampsInc.infuture.

12.ItistheresponsibilityoftheAgencytopaytheparticipantfeebeforecamp.ERCacknowledgesthatAgenciesmayseekacontributionof thisfee fromtheparticipant’s family,however it remains theresponsibilityof theAgencytoensurethatthisfeeispaid.

13.PriortocampERCincurscostsincludingcatering,accommodationandequipment.ERCisthereforeunabletorefundtheparticipantfeeintheeventthattheparticipantcannolongerattendtheprogram.Asanot-for-profit,ERCsubsidisesthefeesthroughfundraising,in-kinddonationsandsignificantvolunteersupport.

I have read and understood the above conditions under which Edmund Rice Camps Inc. conductprogramsinVictoria.BasedonthisinformationIbelievethechildIamreferringforplacementonthiscampissuitedtotheconditionsunderwhichthecampistooperate.

Signed_____________________________________________ Signed_____________________________________________

(AgencyWorker) (Parent/Guardian)

Name______________________________________________ Name_____________________________________________

Date______________________________________________ Date_____________________________________________


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StrengthsanddifficultiesquestionnaireTohelpusplaceyourchildinagroupandtoensurethecamphasabalanceofchallengingandmilderbehaviours,weinviteyoutofillouttheStrengthsandDifficultiesQuestionnaire.Wewillusetheresultsofthisquestionnairegettoknowyouchildabitbetterandtoensurethattheyhavethesupportthattheyneedonthecamp.Thesurveytakesjust3-5minutestofillout.Ifyou’dprefernottofillitout,youcanskipthisbutwewillprioritiseapplicationsthathavefilledoutthesurvey.Thequestionnaireisbestfilledoutbythechild’sprimarycarer.Foreachitem,pleasemarktheboxforNotTrue,SomewhatTrueorCertainlyTrue.Itwouldhelpusifyouansweredallitemsasbestyoucanevenifyouarenotabsolutelycertain.Pleasegiveyouranswersonthebasisofthechild'sbehaviouroverthelastsixmonths.

Nottrue Somewhattrue

Certainlytrue

Considerateofotherpeople’sfeelings

Restless,overactive,cannotstaystillforlong

Oftencomplainsofheadaches,stomach-achesorsickness

Oftenlosestemper

Rathersolitary,preferstoplayalone

Generallywellbehaved,usuallydoeswhatadultsrequest

Manyworriesoroftenseemsworried

Constantlyfidgetingorsquirming

Hasatleastonegoodfriend

Oftenfightswithotherchildrenorbulliesthem

Oftenunhappy,depressedortearful

Generallylikedbyotherchildren

Easilydistracted,concentrationwanders

Nervousorclingyinnewsituations,easilylosesconfidence

Oftenliesorcheats

Pickedonorbulliedbyotherchildren

Thinksthingsoutbeforeacting

Stealsfromhome,schoolorelsewhere

Manyfears,easilyscared

Goodattentionspan,seeschoresorhomeworkthroughtotheend Moreinformationonthisstandardizedquestionnaireavailablefrom:http://www.sdqinfo.com/


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Pleasefilloutthefollowingform.ThecampwillbeheldattheDoxaMalmsburyCampsite.Doxarequireallparticipantstofilloutandsignthenexttwopages.EdmundRiceCampswillgiveDoxaacopyofonlythesetwopages.


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applications close: 5pm friday 31 august, 2018 · phone: 03 8359 0143 mobile: 0408 454 156 email:...

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