JumpStart Leader Registration Register Today! South Island"*" indicates required fieldsName* First Last Preferred Name Gender* Male FemaleDate of Birth* DD slash MM slash YYYY Age*Address* Street Address Address Line 2 City Mobile NumberEmail* Emergency Contacts - Friend or RelativeIn case of an emergency, please list phone numbers where a friend or relative may be contacted during the course of the camp.Friend or Relatives Name First Last Friend or Relative's RelationshipFriend or relative's primary contact numberFriend or relative's secondary contact numberThis field is hidden when viewing the formCamper will arrive by: Bus Plane CarThis field is hidden when viewing the formPlease provide the name of the driverThis field is hidden when viewing the formExpected Arrival Date DD slash MM slash YYYY This field is hidden when viewing the formExpected Arrival Time Hours : Minutes AMPM AM/PMThis field is hidden when viewing the formThe Camper will depart by: Bus Plane CarThis field is hidden when viewing the formPlease provide the name of the driverThis field is hidden when viewing the formExpected Departure Date DD slash MM slash YYYY This field is hidden when viewing the formExpected Departure Time Hours : Minutes AMPM AM/PMDietary InformationDietary Requirements* None Lactose-free Gluten-free OtherOther Dietary RequirementsMedical InformationJumpstart does not supply medications.Do you anticipate you will need to take ANY tablets or other medication during the camp?* Yes NoList any medication you are supplying along with the dose, timing, and reason for it.IF you wish to self-administer medication, you MUST explain.Have you been taken off medication recently?* Yes NoPlease Provide DetailsHave you previously broken/fractured any bones?* Yes NoPlease Provide Further DetailsSpecific Medical ConditionsSpecific Medical ConditionsPlease indicate below, if you have had any of the following. Provide additional details if necessary.In the PastPresentAsthmaDiabetesEpilepsyFits/ConvulsionFaint/DizzinessHyperactivityHypo activityHeart ProblemsAllergy - FoodsAllergy - AnimalsAllergy - OtherPlease provide any further details of any specific medial conditions.Are there any conditions requiring special attention that we should know about?*(e.g. hearing or sight impairment; reading or learning difficulties; ADD or ADHD; behaviour issues; formal counselling situations; other) Yes NoPlease provide any further details about any conditions requiring special attention.Leader Agreement with JumpStart.* I, the Leader, agree to observe the rules and routines of camp, and to participate in the programme arranged.