Outward Bound – Buller Application form

 BULLER DISTRICT SCHOLARSHIP APPLICATION FORM Scholarship Application is to be completed by the applicant
 You must be in the age range of the course you are applying for – course details can be found at: www.outwardbound.co.nz  Scholarship recipients are responsible for the cost of travel to/from Picton and completing an Outward Bound medical form with a doctor.  Outward Bound will contact you upon receipt of all applications, and decisions will be notified in writing.  Confirmation of enrolment is subject to approval from your doctor, and Outward Bound. This is to ensure the applicant’s safety, the safety of others, and quality course outcomes for all. 1. PERSONAL DETAILS Full name Gender Male Date of birth / / Female Age Citizenship/Residency New Zealand Citizen/Resident Australian/Pacific Island Citizen Other Ethnicity NZ European/Pakeha Other European Latin American years Māori Asian Middle Eastern Pacific Islander African Other ‐ state: Postal address Home phone Work phone Mobile phone Fax Email Alternative email School/Education provider Employer/Organisation Job title 2. NEXT OF KIN DETAILS e.g. parent, caregiver, partner etc. Full name Postal address Tick here if same as your address Home phone Work phone Mobile phone Fax Email Alternative email Tick here if your next of kin has done an Outward Bound course ‐ provide their date of birth: / / 3. COURSE DETAILS Course name CLASSIC Course start date Name anyone you know attending the same course OFFICE ONLY Registration Course code Page 1 of 4 4. PERSONAL HISTORY DIETARY REQUIREMENTS None Gluten free Vegetarian exclusive Coeliac Food intolerance Other Provide details e.g. food types, severity and last reaction: Dairy free Cultural/Religious Vegan Food allergy MINIMUM FITNESS Can you comfortably run 3km in under 25 minutes, and complete a full day’s activity? YES NO WATER CONFIDENCE Are you confident in water and comfortable putting your head underwater? YES NO SMOKEFREE Do you smoke? YES NO YES NO If YES ‐ how many do you smoke a day and are you willing to be smokefree at Outward Bound? N/A MEDICAL State your current: Height cm Weight kg if you cannot measure this at home ‐ try your local gym or medical centre Do you have, or have you ever had, any of the below medical, behavioural or developmental issues? ADD/ADHD/Aspergers/Dyslexia Disability ‐ hearing, intellectual, physical, vision Diabetes Serious illness, major operation or knocked unconscious in last year Epilepsy Mental health ‐ anxiety, depression, bi‐polar, schizophrenia, eating disorder Allergic reactions ‐ bees/wasps/foods/medicines Treatment/counselling for alcohol or drug use Asthma Heart conditions High Blood Pressure, fainting attacks or migraine Hepatitis, HIV or AIDS related condition Backache, spinal injury or disc trouble Knee, ankle or joint injury Currently pregnant (‘yes’ will exclude participant) Recent traumatic experiences or death of loved one in the last year Any other medical concerns If YES to any of the above or any current medications being taken ‐ provide details: CRIMINAL Do you have any charges pending, convictions, or have you ever had any involvement with Youth Court? If YES ‐ provide details of all charges, convictions, sentences and dates: 5. PAYMENT (the course fee is not transferrable or refundable) YES NO Your course fee is partially funded by Outward Bound (valued at $4,010 21 day courses; $2,420 8 day courses) I agree to write a thank you letter to the course sponsor during or after the course (see details on your enrolment letter) A $500 deposit towards your course fee is required to enrol ‐ this deposit is non‐refundable except for medical reasons, at which point a medical certificate is required for cancellation I have already paid a $500 deposit online or by phone I am paying $ by cheque credit/debit card ‐ provide details below CREDIT/DEBIT CARD DETAILS Card type Visa Card number Cardholder’s signature Mastercard SIGN HERE Amex Expiry date / Card holder’s name Page 2 of 4 6. WHY OUTWARD BOUND I have attached a letter saying WHY I want to attend Outward Bound and WHAT I hope to get out of the course 7. TERMS AND CONDITIONS PRIVACY Personal information Your personal information will be held confidential to Outward Bound, in accordance with the Privacy Act (1993), for the purposes of Outward Bound courses and associated administration, including promotional activities. You have the right to see all information held by Outward Bound and may ask at any time for that information to be corrected. Ethnicity information is collected for statistical purposes only. You authorise Outward Bound the right to send a copy of your course report to your course fee sponsors, including employers, if requested. Promotional material You authorise Outward Bound the right to use your name, comments and images (video footage or photographs) that are obtained in relation to your Outward Bound participation and to disclose this information to third parties for marketing and public relations purposes; these materials will remain the property of Outward Bound. HEALTH AND WELLBEING Safety Your safety and welfare is our primary concern, however you do participate at your own risk and there are times during your course when you will not be under the direct supervision of staff. Our courses are designed to be mentally, emotionally, and physically challenging for the average participant. Activities occur in all weather conditions and can include off‐track tramping, camping outside (sometimes alone), whitewater and surf kayaking, running, sailing, swimming, rockclimbing and high‐ropes. Days are long and participants cannot always be guaranteed a good night’s sleep. Although we have procedures in place to minimise risk, there is always a chance you could get a cold/flu/stomach bug, blisters, sunburn, exhaustion, wasp stings, infected cuts or insect bites, minor sprain of ankles, wrists or knees, or some other injury. At the time of undertaking any activity, you will be briefed fully on the risks and how to avoid them. If you have an illness or are injured you may be asked not to participate in certain activities, to manage the safety of you, your fellow participants, and our staff. There have been no major life changing injuries at Outward Bound in over 10 years, however serious risks are present such as injury from falling, burns, drowning, hypothermia or road accidents. We have a very robust safety management system, externally audited, to reduce the likelihood of these risks. This system includes well trained staff, up to date weather forecasts, communication technology, modern equipment, safe operating procedures, safety checks, staff driving hour restrictions and emergency procedures. We have a strong commitment to safety and an excellent track record, however none of these risks can be completely eliminated. Smoke, drug & alcohol free Outward Bound has a strict no‐smoking policy. No alcohol or non‐prescription drugs are permitted. Medical form Your Outward Bound medical form must be completed no more than 3 months before your course end date. Your Outward Bound medical form is due 8 weeks before your course start date. If your medical is overdue without prior agreement, and it is declined for any reason, the terms and conditions of a cancellation will apply.
Confirmation of your enrolment is subject to approval from both your doctor and Outward Bound. This is to ensure your safety, the safety of others, and quality course outcomes for all. We recommend you book your travel after confirmation of enrolment. 8. PARTICIPANT’S DECLARATION 
I have read and agree to the above Terms and Conditions. 
I understand that if I do not comply with the above Terms and Conditions, my enrolment may be cancelled or I may be sent home from my course at my own expense. 
I understand that, except as expressly permitted by law, if I give any false information, withhold any relevant information, or do not advise of any new relevant information, my enrolment may be cancelled or I may be sent home from my course at my own expense. 
I am willing to fully participate in my course, comply with all instructions, and respect others, their beliefs and belongings. Participant’s signature SIGN HERE Participant’s name Today’s date / / Page 3 of 4 COMMUNITY PARTNER SCHOLARSHIP ENDORSEMENT Scholarship Endorsement is to be completed by a representative of the organisation that you are associated with  Applicant must be in the age range of the course being applied for – course details can be found at: www.outwardbound.co.nz  Scholarship recipients are responsible for the cost of travel to/from Picton and completing an Outward Bound medical form with a doctor.  Outward Bound will contact the applicant upon receipt of all applications, and decisions will be notified in writing.  Confirmation of enrolment is subject to approval from the applicant’s doctor, and Outward Bound. This is to ensure the applicant’s safety, the safety of others, and quality course outcomes for all. 9. REFEREE DETAILS Full name Work phone Email Employer/Organisation Job title Mobile phone 10. REFERENCE Name of Applicant How long have you known the applicant? years months Please attach a letter telling us WHY you recommend the applicant for an Outward Bound scholarship, or write below: Referee’s signature SIGN HERE Referee’s name Today’s date / / CONTACT DETAILS (return the completed Scholarship Application and Endorsement by Friday June 19th Contact name Rachael Young Postal address Outward Bound PO Box 25274 Wellington, 6146 Phone 0275 487 013 or 0800 688 927 Email [email protected] Page 4 of 4