Back to Basics 2013

Provincial Youth Rally June 29 July 2, 2013 Ganaraska Forest

Registration Package

Back To Basics 2013 Back To Basics is a Provincial SJA Youth Rally with youth attending from across Ontario. It is being held June 29 to July 2, 2013. The Ganaraska Forest Education Centre will be our home for 4 days of learning, testing ourselves to new heights, and fun, fun, fun! One of our days will be filled with challenges run by Tree Top Trekking. We will be doing great group challenges in a low ropes course to build team work. The tree top challenges will test your confidence; take you to new heights and new experiences. The Tree Top Trekking is like an obstacle course in the trees with safety harnesses. Afraid of heights? Don't be - you will be too busy to be scared! Check out their website at www.treetoptrekking.com New to rally this year is a Back To Basics camping in tents experience for many of the attendees. Ages 13 or higher, depending on the age of the registrants, will be sleeping in tents. You will be able to choose your tent mates from your unit - girls and boys will be on separate camp sites of course. You will need to bring a tent and sleeping gear with you. A complete camp list will be sent out on receipt of your application. We are planning other great Back To Basic activities such as wilderness foods, First Nations crafts and skills and so very much more! The cost of the 4 days - meals, tree trekking and other phenomenal activities is only $75 for early bird registration or $95 for later registrants. We will provide you with a t-shirt. In order to make sure we order your size please answer the question on the form based on what size you need. You also have the option to pre-order a USB flash drive full of pictures from the camp for only $10. They will not be available for purchase at camp, only what was pre-ordered will be created. Early Bird Registration and payment are due April 26th and final registration is May 10th. Spots are limited so get in early! Please send a cheque, or money order made out to St. John Ambulance Council for Ontario. Dont forget to check our website for the most up-to-date information at www.back2basics2013.com. Also, dont forget to join us on Facebook (www.facebook.com/back2basics2013) and on twitter (www.twitter.com/back2basics2013) Looking forward to seeing everyone at rally! Marika Beaumont Provincial Youth Advisor Tony Alberts Provincial Commissioner

Back To Basics Youth Rally 2013 Youth Permission Form I ______________________ (parent/guardian) give permission for _______________________ (youth Member) to attend Back To Basics SJA Youth Rally on June 29, 2013 to July 2, 2013-03-13 ___ I have completed and attached the photo release form. ___ I have completed and attached the medical form that is included with this application. If my youth/ward requires medical treatment, I understand that St. John Ambulance will take initial steps to secure medical advice and services and that I will be contacted as soon as possible, or if unavailable, the emergency contact person noted. ____ I understand there are risks inherent in a camp environment. Some of the risks associated with these types of activities include (but are not limited to): scrapes, cuts or bruises; sprains, strains or possible broken bones; illness from known or unknown sources; theft or loss of possessions; and unforeseen injuries from activities, equipment or actions of your youth, other participants or other people. ___ I have completed the TreeTop Trekking Aerial Course Waivier ___ I have included $10 for a Rally USB Flash Drive ___ I have included the $75 early registration fee (BEFORE April 26th ) ___ I have included the $95 late registration fee (BEFORE May 10) ___ My child will be able to bring a ___ person tent to Rally (if over the age of 13) ___ My child would like to be a Junior Leader (age 16/17s only) My child requires a Small Medium Large X-Large T-Shirt. Please list any food allergies or dietary restrictions below: ___________________________________________________________________________________ ___________________________________________________________________________________ ________________________________ Name of parent/guardian ________________________________ Name of Youth Member __________________________. ___________________ Signature Date ___________________________ Signature ___________________ Date

Photo/Video Permission and Release Form

Name of Participant: _____________________________________________________________________________________________ Date of Birth of Participant: ______________________________________ Age of Participant: _______________________________ Parent/Guardian (if applicable): _____________________________________________________________________________________

Please check both boxes below, where applicable: I acknowledge and consent to the following:

On behalf of myself and/or my child, I give permission to St. John Ambulance to record, film and/or photograph myself and/or my child in connection with my/his/her participation in St. John Ambulance activities or events. I agree that all recordings, films and photographs of myself and/or my child that I submit to or that are taken or created by St. John Ambulance (the Materials) are the property of St. John Ambulance and may be reproduced, in whole or in part, by St. John Ambulance in any format (including, but not limited to: newsletters, booth displays, brochures, digital media, public service announcements, online newsletters and on the world wide web). I agree that the Materials may be used or reproduced at any time at the discretion of St. John Ambulance. I agree that St. John Ambulance may discontinue use of the Materials without notice. I agree that St. John Ambulance will exclusively own all rights, including copyright, in the Materials and all components thereof, and that St. John Ambulance may use the Materials throughout the world, in any manner and in all media as St. John Ambulance may deem appropriate. On behalf of myself and/or my child, I release St. John Ambulance from any claims or actions that I or my child may have arising out of the use by St. John Ambulance of any of the Materials by any person. I agree that St. John Ambulance may freely assign the rights granted herein to any third party in the sole discretion of St. John Ambulance. On behalf of myself and/or my child, I waive any rights of compensation or ownership of the Materials.

On behalf of myself and/or my child, I agree that St. John Ambulance may publish or reproduce my or my childs name(s), and location details in connection with the Materials, as required. Authorization:

I am the age of majority* and I am signing on my own behalf.

* Age of majority: 18 years in AB, MB, ON, PEI, QC, and SK; 19 years in BC, NT, NU, NB, NS, NL, YU

Signature:

I am the parent or legal guardian of the Participant and I am signing on behalf of the Participant.
Relationship to Participant: Signature:

Participant Information:
Date Signed: Telephone (H): Telephone (W): Email: Organization: St. John Ambulance Address: City: Province/State: Postal/Zip Code: Country: Canada Ontario

Back To Basics Youth Rally 2013 Medical Form Part 1 of 2 Name: _______________________________ Date of Birth: _______________ Sex ________________ Address: _____________________________________________________________________________ City/Town: ___________________________ Postal Code: _____________________________________ Telephone Number: _____________________ Alternate: ______________________________________ Emergency Contact Name: __________________________ Emergency Contact Relation: ____________ Emergency Contact Phone: __________________________ Doctors Name: ___________________________________ Phone Number: _______________________ Health Care Number: ___________________________________________________________________ Medical History 1. Do you (your child) have special dietary requirements or are you (your child) subject to any allergies (drugs, food, insect stings, etc.)? If so, please list them indicating type of reaction and usual treatment. _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ 2. Are you (your child) subject to any of the following conditions at present? (Please check markall that apply) Asthma Ear Trouble Hay Fever Nightmares Bed Wetting Fainting Headaches Sleepwalking Bronchitis Fear of heights Menstrual Cramps Tonsillitis Convulsions Frequent Colds Motion Sickness Nosebleeds Other (indicate) Please explain the usual treatment for any conditions indicated: _______________________________________________________________________________________

Back To Basics Youth Rally 2013 Medical Form Part 2 of 2 3. Please check mark the following factors applicable to your child, which the leaders should know: Illnesses Operations Immunizations Heart Disease Rheumatic Fever Appendectomy German Measles Hepatitis Mononucleosis Tonsillectomy Measles Pleurisy Tuberculosis Mumps Pneumonia Epilepsy Whooping Cough Poliomyelitis Note any recent illnesses, chronic conditions, operations, or injuries not included above and indicate any medication or treatment necessary: _______________________________________________________________________________________ 4. The Youth Program sometimes includes sports, swimming, hiking, and other physical activities. Would anything prevent you (your child) from fully participating in such a program? Yes No If Yes, please state the particulars: _______________________________________________________________________________________ 5. Has your daughter started menstruating? If No, has menstruation been explained to her? 6. Date of last tetanus shot Yes Yes No No No

(day/month/year)

7. Can you (your child) take acetaminophen? (e.g. Tylenol) Yes

8. What medication(s) would your child be bringing? These must be clearly labeled with your childs name, dosage, and frequency. Please indicate any medications that must be kept with your child at all times (e.g. medications for severe allergic reactions). For children away on an extended outing, it is recommended that all other medications be handed to the Officer-in-Charge, to ensure that medication schedules are correctly followed. _______________________________________________________________________________________ _______________________________________________________________________________________ ________________________________ Name of parent/guardian ________________________________ Name of Youth Member ___________________________ Signature ___________________________ Signature ___________________ Date ___________________ Date