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REGISTRATION FORM

FOR 2ND ASIA-PACIFIC DEAF YOUTH CAMP

First Name: Last Name:
Gender: Male / Female Date of Birth:

Postal Address:

 
Post Code: Town/City:
Country:
Fax: Voice:
TTY:
E-mail address:
Sign Language/s:
I am: Deaf / Hard of Hearing / Other (please state)
Your Association of Deaf:

Additional information so we can provide you with an enjoyable experience at the camp:

Special food or dietary requirements (e.g. vegetarian food)

 

 

Medical Information, for in the event of an emergency (e.g. allergic to penicillin)

 

 

Emergency Contact Details:

Emergency Contact Person’s Name:

Relationship:

Fax:

Voice:

TTY:

E-mail address:

Any other important details that we should be aware of:

 

 

Name:

Signature:

Association of Deaf Stamp:

 

 

Include a support reference from your Association of Deaf

*PLEASE NOTE: The Deaf Association Of New Zealand is NOT liable for anything that happens to participants during the camp.

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