nw boot camp booking form

CHALLENGER BOOT CAMP
BOOKING FORM
Places on this course are strictly limited to 15 participants, and are offered on a firstcome, first-served basis on receipt of this Booking Form and a £50 deposit (nonrefundable) which should be made payable to ‘Challenger Troop CIC’ or see the BACS
electronic payment option below.
Participant’s details
Name: ___________________________________ Date of Birth: _________________
(Please print)
Address: _________________________________ Home Tel No: _________________
__________________________________
__________________________________
Mobile No: ___________________
Height: ________ Weight: ________ Chest:_________ Waist:_______ Shoe size:______
Next of kin: _______________________________
Relationship: _________________
Address: _________________________________ Tel Numbers:
_________________________________ (daytime) ____________________
_________________________________
(evening)____________________
_________________________________ (mobile) _____________________
Challenger Troop CIC is NOT part of the MOD – Reserve Forces or Cadets Forces
Please note that as the parent or guardian you will also be the emergency point-ofcontact throughout the programme and you will need to make provisions to collect your
child should they need to come home at any time, so please do keep your phone with
you at all times.
Medical Details
Does your son/daughter/ward suffer from any allergies? If so please record them below.
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Is your son/daughter/ward taking any regular medication? If so please list below.
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Is your son/daughter/ward allergic to any medication? If so please list below.
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Does your son/daughter/ward have any dietary restrictions or special food needs? If so
please list below.
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
To the best of your knowledge, has your son/daughter/ward been in contact with any
contagious or infectious diseases or suffered from anything in the last 3 months? Please
give details
Are there any other condition/needs (medical or behavioural) you think we should be aware
of?
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Challenger Troop CIC is NOT part of the MOD – Reserve Forces or Cadets Forces
Does your son/daughter/ward suffer from any of the following?
Delete as appropriate
Asthma
YES/NO
Other Chest and Heart Conditions
YES/NO
(Other than mild chest infections, a chest or heart condition may be significant; this includes
any history of bronchitis or wheezing)
Epilepsy
YES/NO
Any loss of consciousness or blackout
YES/NO
(This includes any history of fainting episodes)
Ear or sinus problems
YES/NO
Severe headaches
YES/NO
Any other major illness or injury
YES/NO
Any conditions requiring regular prescribed medication
YES/NO
Any condition requiring regular care or visits to a doctor or hospital specialist
YES/NO
Any other disability
YES/NO
Has your son/daughter/ward received a tetanus injection in the last 5 years?
Details of participant’s GP
YES/NO
Name: ______________________
Telephone Number:____________________
Address: ___________________________
_________________________________________________________________________
Please confirm below that the adult in charge after due consultation with a First Aider or
other member of the medical team, has your authority to refer the candidate to hospital for
treatment in accordance with the injury.
Signature: ______________________________________Date:_____________________
(Person with parental responsibility for participant’s under 18 years of age)
Name :__________________________________________ (Please print)
Challenger Troop CIC is NOT part of the MOD – Reserve Forces or Cadets Forces
PARENT/GUARDIAN CONSENT & DECLARATION
Participant’s name:……………………………………………………………………………..
I give my full consent to the participation of the above in the Challenger Boot Camp 2015
and agree to drop them to the Crown Gate TA Centre by 10am on the 13th April 2015 and be
back to attend the Awards Ceremony and collect them at 1pm on Friday 17th April 2015
I agree to the full cost of the course at £250 (incl. VAT) and enclose a cheque made payable
to ‘Challenger Troop CIC’/have made an electronic BACS payment (delete where applicable)
for £50 as a deposit and understand that this is non-refundable. The balance must be paid
by 23rd March 2015
I give my consent to Challenger Troop taking video/photographs during the course for the
purposes of programme and marketing unless the following box is ticked.
I acknowledge the need for my son/daughter/ward’s obedience and responsible behaviour. I
understand that if my son/daughter/ward breaks the rules agreed with them, then they may
be removed from the course.
I understand that I will be liable for the replacement of my son/daughter/wards uniform to a
limited cost of £45.00 and any loss of equipment on personal issue to a limit of £100.00.
I understand that a full copy of the insurance provided illustrating the extent and limitations is
available on request.
I understand that it is my responsibility to keep Challenger Troop informed as to any
changes in my child/ward’s medical, social and welfare needs where it is likely to affect
theirs and the safety and wellbeing of other students and staff. Any such notification should
be forwarded to Challenger Troop as soon as it is possible to do so.
I accept that as a parent/guardian I will be the emergency point-of-contact throughout the
programme and agree to make provisions to collect my child should they need to come home
at any time, and will have my phone with me at all times, including overnight.
Challenger Troop CIC is NOT part of the MOD – Reserve Forces or Cadets Forces
Supervised under qualified staff the following activities may include:
Kayaking - Rafting – Swimming – Outdoor Field Exercise (including travelling in
vehicles and walking) - Mountain Biking – Trekking Carrying Load – Physical Training
– Command Tasks – Obstacle Course - Competitive Contact Sports – Laser Tag –
Residential Overnight Field Camping – Lighting Fires - Archery – Air Rifle Shooting –
Bushcraft – Campcraft – First Aid
PARENT / GUARDIAN Signature: _____________________________________________
Date: ______________________
(Person with parental responsibility for participant’s under 18 years of age)
PARENT/GUARDIAN Name: ______________________________________(Please print)
Please return these forms, along with the £50 non-refundable deposit to:
Mark Hall, Challenger Troop CIC, Crown Gate TA Centre, Halton Lea, Runcorn, Cheshire.
Should you have any queries regarding your booking please call 01928 717 800 or email
[email protected]
BACS PAYMENT OPTION:
Amount:
£250
Account Name:
Challenger Troop CIC
Sort Code:
40-36-35
Account Number:
11267043
Ref:
NWBC then [Child’s surname]
Please can you phone or email when payment has been made so that we can confirm the
place has been booked and issue your joining instructions. Tel: 01928 717 800
Challenger Troop CIC is NOT part of the MOD – Reserve Forces or Cadets Forces