Complete the registration form below to register for The Apprentice Doctor Pre-Medical Camp 2011
Student's Name
Date of Birth
Age
Gender (male or female)
Phyical Address
Father's Name
Home Phone Number
Work Phone Number
Cellphone Number
Email Address
Mother's Name
Home Phone Number
Work Phone Number
Cellphone Number
Email Address
Custodian Parent (if separated)
School Attending
Grade
Name of Principal
School Phone Number
Phone Number in Case of Emergency
Name of Physician or Pediatrician
Phone Number
List any allergies/surgeries/illnesses
List of chronic medication and instructions for how it is to be taken
Please note:
1. Student will need a copy of the prescription or a letter from attending doctor for travel purposes
2. It is the parent's responsibility to ensure that the student is well informed about the specifics of the medication and prescription
3. It will be the student's responsibility to take his/her medication as prescribed.
Name of person other than parent in case of emergency
Phone Number
Relationship (aunt / friend etc)
Name of another person other than parent in case of emergency
Phone Number
Relationship (aunt / friend etc)
CAMP INFORMATION
THE COURSE FEE INCLUDES:
- All tuition fees Monday to Friday August 2-6, 2011
- One Apprentice Doctor® Foundation Kit with real medical instruments and items.
- One Apprentice Doctor® Stitch up Wounds Kit with real surgical instruments and items.
- One Pulse Oximeter (valued at $99.00)
- One acclaimed "JUMPSTART YOUR LIFE" book.
- The use of numerous medical instruments and disposable items e.g. sphygmomanometer.
- Disposable surgical gowns, surgical theatre caps and gloves.
- The Apprentice Doctor® surgical scrubs at a discount price.
The registration and tuition fee does not include accommodation and meals – options regarding accommodation
will be forwarded per mail/e-mail.
PERSONAL BELONGINGS/ATTIRE:
The Apprentice Corporation does not take any responsibility for the loss of any personal belongings or any medical
items received on the camp.
This is a Premedical Camp and students will require 1 or 2 sets of surgical scrubs to be worn during some of the training
sessions. We will assist with arranging the attire for the students.
CONDUCT RULES:
Students are prospective medical professionals at grade 11 and 12 level – and therefore a high level of
maturity, appropriate conduct and professionalism is expected at all times.
We would like to treat all students as adults – but in the unlikely event of misbehavior the following grounds for
disciplinary action or in extreme cases expulsion from the camp/conference applies:
• Any kind of harassment including physical, sexual, emotional and/or verbal e.g. use of foul language
• Destruction of camp/conference instruments, items or property, fighting, stealing, hitting or abuse of any kind
• The use of illegal drugs, smoking (no medical professional should smoke – lead by example) or use of alcoholic
beverages
• Discrimination of any kind and/or any other inappropriate or unacceptable conduct
• The inappropriate use of mobile phones during training sessions
• Attitude problems.
Mobile/cellular phone policy:
Do not make use of mobile phones during course hours – kindly switch off all mobile phones during training sessions.
Under certain circumstances the student may switch to "silent" or "discreet" modes. Follow up messages and missed
calls during break times.
DO NOT LET YOUR MOBILE PHONE SPOIL THE EXPERIENCE OR DISTRACT THE ATTENTION OF
FELLOW STUDENTS.
To Students...
Use this camp experience to your maximum benefit, ask questions and take part in the practical sessions. Use the
evenings to study. This is no push over course or merely an activity to keep you occupied during the summer holidays
– the course is intended to prepare you for the demanding career path of becoming a medical professional. You
will not receive a certificate unless you pass the theoretical and practical exams at the end of the course!
AGREEMENT AND DISCLAIMER FORM
Due to the nature of the camp, medical examinations (taking blood pressure, heart rate, pupil light reflex etc.) will be
performed and practiced in groups of 2-3 students.
We do have a policy of "no embarrassment" and participation is always voluntary.
No anatomically sensitive areas of students' bodies will be exposed or examined.
For example, students will listen to heart sounds placing the chest piece of the stethoscope over the shirt material. As
far as possible we will have a same-gender (girl-girl and boy-boy) policy during the practical sessions.
1. I hereby state that I will allow my son/daughter to participate in the practical sessions (please also sign separate
form for this purpose).
2. I have clearly explained all Camp guidelines to my child and he/she understands the consequences for failure to
abide by them.
3. I certify that my child's medical records are complete and that he/she is fully immunized and physically and mentally
and able to participate in all physical activities of the program. I certify that my child is covered by a health insurance
policy and that The Apprentice Corporation's insurance will cover immediate EMERGENCY TREATMENT ONLY. The
Apprentice Corporation will not be liability for any further medical expenses whatsoever. I understand that in case
of an accident, I will first submit the claim to my insurance carrier. I agree to be responsible for any hospitalization or
other required treatment.
4. I hereby give permission for my child's photo, group video or group photos to be published in either the Apprentice
Doctor's website or any other publication.
5. I understand that my child will be transported to/from Field Trips (if levels of interest allows) in privately owned,
sub-contracted busses or vans or taxi's and hereby release The Apprentice Corporation, its Directors, Employees or
volunteers of any and all liability that may occur at the school campus, during any of the optional Field Trips (if
applicable).
6. I will not hold The Apprentice Corporation, its directors, employees or volunteers liability for loss of any personal
belongings, equipment, e.g. laptop computers, mobile phones, etc. or any medical instruments and items received
from The Apprentice Corporation.
7. I understand that no deductions will be made for days absent due to sickness or any other reason.
8. I understand that all payments made before 18 June, 2011 are refundable (a 15% admin fee will be deducted though). All
payments after 17 June, 2011 are non-refundable.
9. I have read and understand the "Camp Information" provided by the supplier of this application (see
above).
10. I have read and understand and signed the "Agreement and Disclaimer Form" provided by the supplier
of the
application (see above).
11. I hereby request the teacher/supervisor to inform me should there be any concerns regarding possible
abnormalities found during a practical session.
12. I give permission to my son/daughter to sign the confidentiality form (below).
Parent:
Date:
I,
, the parent/legal guardian of
(full names of student) hereby grant permission
to
(full names of student) age
, to take part in educational exercises pertaining to various medical
topics.
Signature of Parent/Guardian: ________________________________ (please print this form with all completed details, scan and fax back to us)
Relationship to Child:
Student:
I,
, age
, promise to regard all information regarding the
health of any person taking part in the practical project in The Apprentice Doctor® course as strictly
confidential.
I undertake not to reveal any medical information coming to my knowledge during the conduct of any practical
project to anybody else with the exception of the following:
Specific concerns regarding possible abnormalities may be reported to the teacher/supervisor with the
permission of the specific individual concerned. The relevant individual's parents/legal guardian will then be
notified with the request to pursue professional medical advice.
Signed on date:
Student Sign:……………………………………
Project Leader (Dr Anton Scheepers) .........................................................................