Hillary DoE Award Adventurous Journey Registration 2016

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Please fill out this form to register on a Hillary Duke of Edinburgh Adventurous Journey supported by Horizons Unlimited. We will check this register regularly and reply with more detail for you to prepare for your journey.

First Name *

Last Name *

Email address *

This is the primary way we will be sending you key information on this journey.

Postal Address

We may need to send you information by post.

Award level *

Choose which journey you would like to sign up for.

Do you have any medical conditions or impairment which may effect your ability to participate in the journy? *

This information will allow instructors to be aware or adapt journey activities if required. Please include such things as: hearing or vision impairments, asthma,chronic medical conditions, severe allergies and recent illnesses and surgery.

Yes

Required

If "Yes" to above please describe below. Include further information here.

If you are taking medication please describe the following: medication name, dose quantity and frequency. Please ensure you have this medication with you.

Does you have any specific dietary requirements or food allergies?

Yes

If "Yes" to above please describe specific dietary requirements below:

You will be planning and preparing your own meals - but it is helpful for us to be aware of this information.

I would describe my swimming ability as:

This is helpful to know incase we stop for a swim along the way!

Confident - can swim 50 metres or more

Average - can swim 25 metres or more

Beginner/Non swimmer - can swim 10 metres or less/can float

I authorise Horizons Unlimited staff to obtain medical assistance on my behalf in an emergency.

I accept

I DO NOT accept - and would like to discuss further.

Journey fee of $230 for Bronze and $260 for Silver and Gold.

This fee is 'per journey' and will be charged to you by invoice - sent to the email above. We appreciate prompt payment of this.

I agree to pay the journey fee of $230 for Bronze

I agree to pay the journey fee of $260 for Silver and Gold.

Parent or Guardian Name - If you are under 18years old this section is to be completed by your Parent or Guardian.

Name of parent or guardian - so we know who to contact in an emergency..

I agree that my child should take part in all DoE Adventurous journey activities. I understand and accept the risks.

The acivities for this journey are: tramping and camping. These activities will be lead by a trained and qualified instructor from Horizons Unlimited. Horizons is a Christchurch based Adventure Education provider - Horizons' holds ‘OutdoorsMark’, New Zealand’s leading outdoor safety audit certificate, and is registered with Worksafe NZ as an Adventure Activities provider - as required under the HSE (Adventure Activities) Regulations 2011 . Thorough hazard management, staff training, equipment checks and emergency response systems are in place. Horizons safety management system can be viewed on request at: info@horizons.co.nz.

DO not accept and would like to discuss this further.

Phone number (parent or guardian)

Please write the moblie number of your parent or guadian here.

Home (or other) phone number (parent or guardian)

Please write another phone number here - so we can contact your parent/guardian if your first phone number does not connect.

What else?

Please llist here any specific questions yu have regarding this journey - or anything that might be helpful in helping us prepare for these trips!

Thank you - we will be in touch with you shortly. We look forward to planning and supporting you to have a fantastic adventure.

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