Camp Registration — LangDentity

My Roots, My Pride Camp Registration

(NOTE: This form can only completed by someone who is 18 years or above)

Friday 22 September 2023 - Sunday 24 September 2023
Killalea Bunkhouse in Killalea Regional Park is located between Shellharbour and Kiama,
Killalea Drive, Shell Cove, NSW, 2529

Name of Adult Bringing Child/Children to Camp

First Name

Last Name

Mobile Number

Is the Adult staying overnight?

No

Fri Only

Sat Only

Both Nights

Name of First Child

First Name

Last Name

Gender of First Child

Age of First Child

Name of Second Child

First Name

Last Name

Gender of Second Child

Age of Second Child

Name of Third Child

First Name

Last Name

Gender of Third Child

Age of Third Child

Name of Fourth Child

First Name

Last Name

Gender of Fourth Child

Age of Fourth Child

Dietary Restrictions or Allergies

Please let us know any dietary restrictions or allergies for any of the attendees

Anaphylaxis plan

If applicable, please let us know the Anaphylaxis plan in case of emergency

Name of Emergency Contact

First Name

Last Name

Address of Emergency Contact

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email of Emergency Contact

Mobile Phone of Emergency Contact

(###)

###

####

Confirmation of Understanding of Risks

By submitting this form and signing your name below you confirm that you have read the safety instructions/warnings here: www.langdentity.com.au/riskwaiver

Name of the Person Completing the Form

First Name

Last Name

Today's Date

MM

DD

YYYY

My Roots, My Pride Camp Registration

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