Please note all information will be kept strictly confidential.

Full Name (Parent/Guardian 1)

WWCC No and Expiry Date

Full Name (Parent/Guardian 2)

WWCC No and Expiry Date

Working With Children Card details are not required to join Camp Autism WA but must be supplied before you will be able to attend an overnight camp.

Postal Address

Phone number

Email address

Names and Date of Births of Children

List any disabilities or health issues and the family member to which it relates

List any allergies or food preferences and the family member to which it relates

In case of emergency contact/s (other then parents/guardians listed above)

Bank Account details

Bank: ANZ BSB: 016-352 Acc No: 378743826 Account Name: Camp Autism WA Inc Please ensure the reference used for the payment is the surname and initial of the parent.

Please check the following item/s

I have read and agree to the Camp Rules
Deposits for camp/s are required by the designated due date to secure my position
I authorise Camp Autism to organise medical attention should it be required.

Please check only if you have any of the following photo resctrictions:

Not to be used in the General Camp Autism WA facebook page
Not to be used in the Financial Members only Camp Autism WA facebook page
Not to be used in any website/advertising material