Jabiru Practicum Application 2022

First Name *

Last Name *

Street Address *

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City *

State/Province/Region *

CAMP JABIRU 2022 PRACTICUM APPLICATION

Important Dates:

Practicum Lecture Day - 8th April 2022 (Held at The Sensory Gym®)

Camp Orientation - 9th April 2022 (Held at Camp Yarramundi)

Camp Jabiru - 10th-14th April 2022

Zip/Postal Code *

Phone Number *

Country *

Email Address *

Place of Employment *

Brief Job Description *

Liability Insurance Policy Provider *

Liability Insurance Policy Number *

Education and Degrees Held

Continuing Education Courses (Title, Instructor, and Date)

Reason for Applying to this Program *

What do you hope to learn from this experience? Please state your goals for participation. *

Please list any special interests and/or skills you might be able to contribute at camp (i.e. music, sign language, leadership, creativity, etc.): *

Which age range would you be most interested in working with? *

4-8 years old (Day campers)

8-12 years old (Overnight campers)

8 years old (Transition campers: day campers/overnight one night)

12+ years old (Jabiru 2.0--Overnight campers/apprentice program)

No preference

T-shirt Size *

Please list any special dietary needs (note there is an additional $25 fee for gluten-free meal provision during camp) : *

Please list any allergies (i.e. foods, drugs, insects, plants): *

Please list any health issues you suffer from including chronic injury, illness, and/or emotional disorders (i.e. asthma, chronic fatigue syndrome, depression, etc). *

Please list anything that would restrict your participation in activities at camp (i.e. back injury, fear of heights, etc.). *

How would you rate your swimming ability? *

Unable (Nothing more than dog paddle)

Poor (Basic strokes, only limited strokes beyond domestic swimming pool)

Good (Strong swimmer, able to swim confidently in a variety of water conditions)

Excellent (Very strong and confident, could swim 50 mtrs fully clothed)

Would you like to stay overnight at camp on the 8th April 2022 (note there is an additional $55 fee for staying overnight on this date)? *

Yes

Is there anything else you would like to share with us? *

Please attach a copy of your current working with children check. *

Please attach a recent photo of yourself. *

Please attach your completed YMCA medical form. *

Please note: Applications will be taken until positions are full. The amount of $1800 is payable with your application. Please include $25 if you are requesting a gluten free diet and $55 if you want to stay at camp on the night of the 8th April 2022. All payments will be refunded immediately if a place is not made available to you. Payment methods include direct deposit or credit card (please note that a 1.155% surcharge will be applied to credit card payments). Your $1800 fee includes meals and lodging at camp (arriving 9th April 2022 and departing 14th April 2022) as well as your professional development experience.

I will pay by *

Direct Deposit

Credit Card

Please provide the following information:

Name on Credit Card *

Credit Card Type *

Credit Card Number *

Expiration Date (mm/yy) *

To pay by direct deposit, please remit full payment to:

Acct Name: The Sensory Gym Pty Ltd

Bank: St George

Branch: Richmond

BSB: 112 879

Acct No: 491 763 765

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