2011 Australia Pacific Conference Registration Form

Complete form in BLOCK LETTERS

Participant Information
First name Last name Male Fema School Date of
le Grade Birth

Address
Postcode

Program Information
Program Name Venue
CFC Australia Youth for Christ Rostrevor College
Australia-Pacific Conference Glen Stuart Road Woodforde , South Australia

Date From Date To Travel Requirements (Interstate Pick up point

15 April 2011 17 April 2011 Participant)
The Transport Coordinator will advise the designated
Arrival Ye N Drop off point
pickup/drop off points at the Adelaide Airport for Friday, s o
15 Apr 2011 and Sunday, 17 Apr 2011.
Departure Ye Ye
s s

Comments
If arriving prior to 15 April, do you require Ye N
hosting? s o
If staying after 17 April, do you require hosting? Ye N
s o

Parent/Guardian Contact Details

Please indicate a 24 hour phone contact for the duration of conference.
Home Number Mobile Number
Father
Mother
Guardian
Home email address
Work email address

Payment Method (please choose one payment option below and complete the details)

Amt Paid Date Received

1 Cash Payment handed to Couple Coordinator (insert name
$ / /
)
2 Cheque Cheque/money order payable to Couples for Christ Australia is
attached. Please write the name of the delegate/s at the back of the $ / /
cheque.
3 EFT Payment deposited to Couples for Christ Adelaide account.
Bank Name: NAB BSB No: 082133 Account No: 792588251.
$ / /
Pls use reference as YFC Conf (first initial) then (last name ). Eg. YFC
Conf JSmith

Health Details and related information

Does the participant suffer from the following? (If yes to one or more, please attach details as required)

A current A disability / chronic Any allergic Asthma (include asthma Bed wetting
illness illness condition plan)

Attention deficit disorder Behavioural Diabete Epilep Sleep Skin condition

problems s sy walking

Other
Participant’s name
Special requirements and dietary needs
Please identify any special needs or requirements not listed above (eg diet, wheelchair access, etc.)
Disclaimer
Please note
1. The full conference fee must accompany the booking;
otherwise the booking will not be accepted.
2. Booking is necessary prior to the commencement of the
program to secure your place.
3. Conference fees must be received by CFC Australia Youth
for Christ – SA prior to the end of the Early Bird Discount
Period in order to avail of the Early Bird Discount.
4. All conference fees must be received in full on or before 2
April 2011.
Couples for Christ Australia will collect and store the
information you provide to enable processing of bookings to
the conference. The information will be provided to the Youth
Leaders and Couple Coordinators, where necessary, and you
consent to this disclosure. Any information provided by you
will be stored on a database that will only be accessed by
Couple Coordinators and Youth Leaders and is subject to
privacy restrictions. The information will only be used for the
purpose for which it was collected.
Refunds and cancellations
Requests for refunds must be made fourteen (14) days prior to
the commencement of the conference. All requests must be
made in writing. All refunds are subject to an administration
fee of 20% of the total conference fee. Refunds will not be
given for partial attendance. Refunds will be paid at the
completion of the conference. CFC Australia Youth for Christ
reserves the right to cancel any program. Every effort will be
made to give reasonable notice to those who have enrolled
when a program is cancelled. Those enrolled will be given a
full refund.
Medicare Number Position on Valid till
card
Risk waiver and media consent
a) I agree to my child’s/ward’s attendance at the conference
noted above. In case of an emergency, I authorise the
Couple Coordinators, where it is impracticable to
communicate with me, to arrange for my child/ward to
receive such medical or surgical treatment as may be
deemed necessary. I also undertake to pay or reimburse
costs which may be incurred for medical attention,
ambulance transport and drugs while my child/ward is
enrolled with the program. I understand that although CFC
Australia Youth for Christ and its service providers attempt
to minimise any risk of personal injury within practical
boundaries, accidents do happen and all physical activities
carry the risk of personal injury. I acknowledge that there
is an inherent risk of personal injury in physical activities
that will be undertaken as part of the program, and
b) Please tick whichever applies to you
o I consent
o I do not consent
To allow CFC Australia Youth for Christ to use my
child’s/my ward’s name and any photographs, sound and
film recordings taken of my child/my ward at this program
for the promotion of CFC Australia Youth for Christ services
and initiatives to the media and to the general public.
Please tick Parent Guardian
Full name (print)
Signature Date