We’re so excited to see you in January, please fill in this form to let us know which program you would like to attend.We will endeavour to support as many people as possible, however, due to group size limits we cannot guarantee a spot in every activity. Official program allocations will be provided in December. Participant Full NameFirstLast Participant Date of Birth01020304050607080910111213141516171819202122232425262728293031day / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecembermonth / 202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901year Participant Address Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code AfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d’IvoireCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWalesYemenZambiaZimbabwe Country Parent/Guardian NameFirstLast Parent/Guardian Phone Parent/Guardian Email Preferred Contact MethodEmailPhone Please select the camps you are interested in:Camp Uproar 14-18yrs 4th-8th JanCamp Inspire 8-12yrs 11th-13th JanCamp Empower 12-16yrs 18th-20th JanCamp MISFIT, 18-25yrs, 21st-23rd Jan Please select the activities you are interested in:Games Day 9th Jan (12+yrs )Gumbuya World 10th Jan (8+yrs)24 hour film 14th -15th Jan (16+) Musical Theatre, 16th Jan (12+ yrs)Dungeons and Dragons, 17th Jan (8-12yrs, 12-16yrs, 14-18yrs, 18+yrs)Art Day 24th Jan (8-16yrs)Beach Day 25th Jan (10+ yrs) In the event of an accident, injury or illness, I authorise a member of The Misfit Project Staff to seek medical intervention for the participant.*YesNo I give permission for the partipant to be administered Paracetamol (Panadol) as per manufacturers instructions by a supervising adult if deemed necessary.YesNo Please provide us with any medical or mental health information we need to know support you to access our programs Is the participant taking any regular medications? (If yes we will get in contact so you can fill in an up to date medication form)YesNo Please list any allergies below The MISFIT Project hopes to use imagery to highlight project achievements, for training purposes and for social media use (including advertising). Please indicate whether you give permission for the above uses.I give permission for use across all platformsI do not give permissionI would like to arrange specific conditions for the use of imagery (please specify) I am aware that at anytime I have the right to withdraw consent (in writing). YesNo Does the participant have an NDIS plan?YesNo Emergency Contact Name (different from the Parent/Guardian listed above)FirstLast Emergency Contact Phone Relationship to Participant? We know this year has been hard, are there financial barrier for you to access our programs? If so, are you happy for us to get in touch to see how we can help?YesNoSubmitReset
