Up!Club Participant Support Details Form

Activity: UP! Club Overnight Camp

About You

Participant First Name *

Participant Last Name *

Participant preferred name:

Mobile Number (if you have one): *

Do you have a Companion card?

YesNo

If Yes, Companion Card Number:

Do you acknowledge the price cost and agree to pay the fee? *

YesNo

Will you be bringing a support worker/carer with you? *

YesNo

If yes, what is the Support Worker/carer name?

Email:

Phone:

Role/Relationship:

Will you be meeting at Central Station or the overnight location?

CentralOvernight Location

Will you be getting picked up at Central Station or the overnight location?

Central (Private Bus - Extra Costs)Overnight Location

Emergency Contact 1

Parent/Carer name: *

Parent/Carer mobile number: *

Parent/Carer email address: *

Relationship to participant: *

Emergency Contact 2

Parent/Carer 2 name:

Parent/Carer 2 mobile number:

Parent/Carer 2 email address:

Parent/Carer 2 relationship to participant:

Medical Information

Please note Down Syndrome NSW use this information for risk identification and mitigation purposes. We do not administer or provide reminders for medication during our activities.

Do you have any medical conditions or disability *

YesNo

If yes, please specify

Do you have food allergies or dietary requirements? *

YesNo

Please provide details:

Will you be taking any medication while you are away? *

Yes (Please provide details below)No

If yes please specify medication name, dosage, method given, time and frequency.

Please note Down Syndrome staff and volunteers do NOT provide any medication assistance.

Activities

Are you comfortable walking for long distances (500m - 1km)? *

YesNo

Swimming Competency? *

NoneLowModerateAdvanced

Are you comfortable with heights? *

YesNo

Communication and Support

How do you Communicate? *

Verbal - EnglishVerbal - OtherNon-VerbalOther

If you selected Other please specify:

Please advise if you have any other accessibility needs/verbal needs/support needs:

Do you have a Behaviour Support Plan? *

Verbal - EnglishVerbal - OtherNon-VerbalOther

If yes, please provide us with a copy of your Behaviour Support Plan.

Browse

Have you been away overnight without your parents? *

YesNo

Do you need assistance with getting on and off public transport? *

YesNo

If yes, please provide us with details of support required.

Do you have any mobility requirements? *

YesNo

If yes, please provide details:

Do you have any concerns about going away? *

YesNo

Acknowledgement

Please read the below, tick to acknowledge and sign below:

I have communicated all relevant information to help make my time away a fun environment for me. *

I am a Down Syndrome NSW Member. If I am not, I consent to being signed up as a member. Membership is free. *

I have a current Service Agreement and Scheule of Support with Down Syndrome NSW. If you do not, do not tick this box and we will send you one.

I understand that DSNSW will collect and keep my personal information, using it for the staff and volunteers only to best support me. It will be kept secure and only used for this purpose. I consent to this. *

I am happy for photos/videos to be taken of me during this event that may be used for DSNSW communication and/or marketing purposes. *

I have read and acknowledged the cancellation policy. *

Signature

Signature of Participant (Typing your name is acceptable) *

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Signature of Primary Contact (Typing your name is acceptable) *

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Date: