Gold Application Form (amended)

RED KITE Expeditions
www.redkiteexpeditions.net
GOLD APPLICATION FORM
Please complete all sections
Participant:
Surname:
25 Hampden Square
Fairford Leys
Aylesbury
Buckinghamshire
HP19 7HT
Forename:
Likes to be known as:
Sex:
Mobile phone number:
male/female
Date of birth:
Primary address:
Post code:
Preferred e-mail address:
School:
Licenced Organisation:
(BucksCC/Scouts/Guides/etc)
eDofE number:
You must buy a Welcome Pack from an Operating Authority before you can expedition with us. This could be Bucks County Council if you like. Contact
The Duke of Edinburgh’s Award, Youth Services, 1st Floor County Hall, Aylesbury, HP20 1UZ. Tel: 01296 382889. Email: [email protected].
Completed Bronze
Award? YES/NO
Date:
Completed Silver Award?
YES/NO
Date:
Parents or Guardians:
Contact 1:
Surname:
Forename:
Phone:
Mobile:
Work:
Contact 2:
Surname:
Forename:
Phone:
Mobile:
Work:
Relationship to participant: Contact 1 ________________________
Address (if
Contact 2 _________________________
different):
Post code:
Preferred e-mail address:
Home phone number:
Alternative contact person:
Name:
Mobile:
Home phone:
Medical/Disability/Special Educational/Behavioural Needs Information
YES/NO
If YES, it is important that you fully explain the condition, its management and - as appropriate medical treatment including medication. (Please attach additional information if necessary)
Details:
Pain/Flu Relief Medications
Please outline any pain relief remedies your son/daughter may be given if necessary
Details:
Allergies to Medication
Please write NONE, or specify
Details:
Special Dietary Requirements
Please outline any special dietary requirements for your son/daughter. Please be precise.
Details:
Date of Last Tetanus Injection
Details:
Year:
Month (if known):
Doctor:
Name:
Surgery:
Phone:
Statement of Risk
Red Kite Expeditions (RKE) places safety as a top priority. Adventurous Activities involve some risk for the
people taking part: we aim to keep these risks as low as possible. The chances of a serious injury are extremely
low, but minor injuries (bruises, bumps and - less likely – minor fractures) are a possible result of taking part
in Adventurous Activities. RKE’s staff will minimise actual dangers by:
• Carrying out a careful assessment of all risks before commencing the activity
• Only using experienced instructors with the appropriate qualifications for the activity
• Giving clear safety instructions to everyone participating
• Ensuring equipment and clothing is well-maintained and suitable for the activity and the environment
• Ensuring activities are within the capabilities of the participants
• Asking participants to supply information on any medical conditions
• Ensuring good hygiene standards are kept
We expect participants to co-operate with RKE staff, to ensure safety of all participants by following
instructions and answering questions honestly about any medical conditions or other information relating to
health and safety.
Photo Consent Declaration
I agree to images being taken of my son/daughter whilst on this trip which may be used in local publications,
on Red Kite Expeditions noticeboards or website to promote the work of Red Kite Expeditions.
(These images will not be used in any way that may be viewed as negative in tone, or that may cause offence, embarrassment or
distress to the child or their parent/guardian.)
Signed:
Date:
Declaration
I agree to my son/daughter taking part in the activities outlined above. I understand that my son/daughter will
take part at his/her own risk, and accept that no responsibility for accidents or injuries, or loss or damage to
personal property rests with the supervisory staff, unless proven to be caused by their negligence. I declare that
to the best of my knowledge my son/daughter is competent and medically fit to participate as part of the
group. I agree that medical treatment will be given if necessary and in case of emergency. I understand the
information from this activity may be stored digitally. I agree that a similar activity may be substituted due to
safety factors or weather conditions.
I agree that in the event of my son/daughter being removed from the event due to his/her unacceptable
behaviour that I will bear the costs of collecting him/her and returning him/her to home.
I have read and understand the statement of risk assessment associated with walking and camping
unaccompanied in wild country areas but with remote supervision by trained staff.
Signed:
Print Name
Date:
RKE Basic Training Weekend (This is optional if you attended RKE’s Basic Training for your Bronze or
Silver Expedition.)
Please select your choice of date from the following (delete as appropriate)
28th/29th March 2015
23rd/24th May 2015
£50
Wild Country Training/Practice Expedition
Please confirm your attendance for the dates below
Event
Expedition
Route Planning
Kit Check
Howgills
4th – 10th April 2015
8th Feb 2015 (daytime)
26th March 2015 (evening)
£275
Snowdonia
25th – 31st July 2015
21st June 2015 (daytime)
21st July 2015 (evening)
£175
Assessed Expedition
Please select your choice of date from the following (delete as appropriate)
Event
Expedition
Route Planning
Kit Check
Snowdonia
25th – 31st July 2015
21st June 2015 (daytime)
21st July 2015 (evening)
£175
Yorkshire Dales
22nd – 28th August 2015
4th July 2015 (daytime)
18th August 2015 (evening)
£175
First Aid Course – The Award requires you to have a minimum of 2 hrs tuition in First Aid.
Red Kite are happy to offer eight hour courses on the following dates which are valid for three years
8th November 2014 (daytime)
7th December 2014 (daytime)
17th January 2015 (daytime)
8th February 2015 (daytime)
7th March 2015 (daytime)
19th April 2015 (daytime)
Alternatively, if you have an existing First Aid Qualification it may be sufficient. Please check with us.
Payment Details
Payment is required with this form and can be made in one of three ways:
Cheques payable to: Red Kite Expeditions and posted (with this form) to the address above
By bank transfer to: Red Kite Expeditions
Account No. 02057999
Sort code: 40 08 39
£20
By Paypal to: [email protected]
* Full payment is required with your application to secure your place (UK)
In the event of you having to cancel your involvement, we only guarantee to refund 50% of the cost always
provided:
*
6 weeks notice is given - Snowdonia
Prices are based on a minimum of ten. We reserve the right to cancel if there are insufficient numbers.
Spaces on training and expeditions will be limited so you should be aware that Red Kite Expeditions operates
on a first to pay, first to be accepted basis and we don’t guarantee to be able to allocate an expedition to a
participant where payment has not been received.
Training is dependent on willingness and participation. Red Kite Expeditions do not guarantee to be able to
train every participant in the time stated. There may be a charge for any extra training needed.
Should you need to cancel your involvement, we will refund 50% of the cost of the event provided 6 weeks
notice is given.
Route Planning and Kit Checks will be held in Aylesbury (venue to be confirmed) and start at 18.00
(evenings) or 09.00 (daytime)
If you wish to contact us:
e-mail: [email protected]
or call: 07528 578949