March 2013 holiday for adults with an acquired brain injury

Book now for this years camp for adults with an acquired brain injury, taking place 21 - 24 March 2013. If you have trouble filling out this form please email HigherGroundSA@gmail.com. Please ensure that you fill in every section of the form. Please note: When filling in telephone numbers do not leave any spaces (eg. 0720390907 not 072 039 0907).

Camper Name (Required)

Legal Guardian Name (Required)

Date of Birth (Required)

/ /

Age (Required)

Gender

Male
Female

First Language

Have you attended camp before?

Yes
No

If yes, when?

Home Telephone Number

Cellphone Number (Required)

Email address

Fax Number

Postal Address

Home Address

Emergency Contact (Required)

(Please provide Name, Relationship and Telephone Number)

Second Emergency Contact (Required)

(Please provide Name, Relationship and Telephone Number)

Medical Information (Required)

Please list all medical details (including nature of disability, current medical issues, past medical issues, previous surgeries). We want to make sure we provide the best possible level of care and in order to do this we need to be made aware of all issues, big and small. Please take time to fill out this section in detail.

Behavioural Problems

Should any behavioural problems exist please detail them here. This will help us to ensure that we provide the best possible care and assign the most suitable volunteer.

Assistance Needed (Required)

Please list all assistance needed eg. remind to brush teeth, assist in and out of shower, short term memory - make sure Joe does not wander off alone.

Additional Information

Please give any other additional information not already covered

Do you have Medical Aid? (Required)

Yes
No

Medical Aid Scheme and Number

Do you have any dietary requirements?

Please provide details

Fees

This camp has been sponsored by the KZN Department of Sport and Recreation. There are 20 spaces available. Sponsorship covers food, accommodation and activities.

Transport

The venue for the holiday is Koinonia Conference Centre in Bothas Hill. It is about 20 minutes from Durban. Please arrange transport to and from the venue. Should you have trouble with getting to Koinonia please try to arrange with another participant to get a lift (or call Higher Ground).

Permission to use photographs (Required)

Photographs taken at camp are sometimes used in promotional presentations, printed matter and on our website. Do you consent for your photographs to be used?

Confirmation (Required)

I hereby confirm that all information listed is correct. I acknowledge that I will need to complete an Indemnity and Medicine Form before going to camp.

Higher Ground South Africa

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March 2013 holiday for adults with an acquired brain injury