Application to Attend Activity – Australian Cadet Corps (ACC)

Activity Type *

Please select the type of activity you are submitting an application for.

Name of Activity *

Please provide the name of the activity (ie: Cadets Camp or ANZAC Day Services)

Date of Activity

Provide the start date of the activity

Unit *

Provide the name of the unit the member is attached to or the name of the unit that is holding the activity.

Attendee Details

The following fields will ask information about the person attending the activity.

Name *

First

Last

Medicare Card Number *

This is a 10 digit number that appears above the name of the attendee across the top of the card.

Medicare Reference Number *

Please provide the single digit number listed next to the name of the attendee.

Use details we have on file? *

Before continuing, please choose one of the following options.

Date of Birth *

Attendee Home Address *

Address Line 1

City

State / Province / Region

Postal Code

Attendee Gender *

Attendee Contact Phone Number

Please provide the best contact number for the attendee (if one is available). This is not an emergency contact.

Attendee Email

Please provide the email address used by the attendee (if one is available). This is not an emergency contact.

Private Health Insurance provider (if known)

Provide the name of the private health insurance provider for this attendee (if available)

Blood Group (if known)

Please provide the blood group of the attendee if known.

Date of last Tetanus injection (if known)

Please provide the date (or rough time period) the attendee last received a Tetanus injection if known.

Medical and Dietary Requirements Check *

Attendee has NO Medical/Physical Conditions or Dietary Requirements
Attendee has Medical Conditions and needs supervision with medications
Attendee has Medical Conditions and can self medicate
Attendee has a Physical Condition and requires assistance with mobility
Attendee has special needs or an other noteworthy requirement
Attendee has Allergies
Attendee has Dietary Requirements

Please tick any that apply to the attendee (you can choose multiple).

Medical Conditions and Medications

Please list all known medical conditions and list the medications that the attendee is likely to take while at the activity.

Physical Conditions or Special Needs

Please list the physical or mental conditions and/or any special requirements needed by the attendee.

Allergies or Dietary Requirements

Please list all known allergies and/or list the foods that can not be eaten by the attendee.

Emergency Contact Details

The next few fields will ask for the emergency contact details of the attendee. Ideally this should not be a person also attending the same activity.

Name of Emergency Contact *

Please provide the name of the emergency contact we will reference for the attendee.

Relationship of Emergency Contact *

Please provide a description of the type of relationship held between this emergency contact and the attendee. (Eg: mother, uncle, etc)

Emergency Contact Number *

Please provide the contact number of the emergency contact listed above for the attendee.

Secondary Emergency Contact Number

If desired, please provide a second phone number as an emergency contact number. This can be a mobile or the phone number of another parent / guardian.

Acknowledgment and Indemnity

I agree to indemnify and keep indemnified the Australian Cadet Corps Inc. and its members to the extent of which the Australian Cadet Corps Inc. and its members are not indemnified under any insurance policy against any damages, claims, illness, demands or any other occurrence which may eventuate or happen to the applicant during their participation in this activity, function, communication or travelling to or from this activity or function connected with, or in relation to, the Australian Cadet Corps Inc. including any liability for death or personal injury. I further authorise any adult member of the Australian Cadet Corps Inc., where it is impractical to communicate with me, in the event of any incident, accident, illness or mishap, to obtain any necessary medical assistance or treatment and for this purpose to engage doctors, nursing assistance or hospital accommodation and, if emergency operations are required, I authorise the administration of anaesthetic and operation by a surgeon at their direction and in this event I agree to pay all expenses, costs and fees of whatsoever nature other than fees and expenses recovered under any insurance policy which the Australian Cadet Corps Inc. may have in place from time to time and I agree to pay all such costs, expenses and fees to the Australian Cadet Corps Inc. on demand. I further agree that the applicant will be bound by the Australian Cadet Corps Inc. constitution, code of conduct and other rules and policies in place from time to time and I agree to regularly inform and update the Australian Cadet Corps Inc. in relation to any change of the applicant’s personal details and medical conditions affecting the applicant. I acknowledge having read and understood this indemnity statement and membership agreement and further state that all particulars included on this form are correct at the time of signing.

I, *

First

Last

Name of the applicant (if over 18 years old) or the name of the Parent or Legal Guardian where the applicant/attendee is a minor.

acknowledge having read the Indemnity Statement above and that all particulars included on this Form are correct at the time of signing.

Signature of Applicant or Parent or Legal Guardian *

Clear Signature

Signature of the Applicant (if an Adult) or Parent or Legal Guardian where the applicant/attendee is deemed to be a minor under respective law.

Email for confirmation *

Email

Confirm Email

Please provide the email address of the person signing this form.