Crossley Heath DofE Form 2017/2018 If you are human, leave this field blank. Parent/Guardian Emergency Contact Details Parent/Guardian First Name * Parent/Guardian Surname * Parent/Guardian Email Address * Home Phone Number * Mobile Phone Number * Additional Phone Number Participant Details What level would you like to enrol for? * Bronze Group 1 Bronze Group 2 Either Bronze Group (I don't mind) Silver (Holds Bronze Award) Direct Silver Gold UK (Holds Bronze/Silver) Direct Gold UK eDofE Number (if known) Participant First Name * Participant Surname * Participant Email Address * Mobile Phone Number * Male/Female * Male Female Age * Date of Birth * First Line of Address * Postcode * Does the participant suffer from any of the following conditions, have any special requirements or recent injuries? * Asthma Epilepsy Allergy Recent Injury Recent Illness Disability Dietary Requirement None Please tick ALL boxes that apply Please provide additional details regarding your condition/requirements/injuries/illness etc * Consent Details & Declaration DofE: Consent to enrol from parent or guardian (if applicant is under 18 years old) I agree to my son / daughter / ward doing a DofE programme. I note that it is my responsibility to check that any activity my son / daughter / ward undertakes for their DofE programme is appropriately managed and insured, unless the activity is directly managed or organised by their DofE group, centre or Licensed Organisation. * I agree C I Adventures: Participation and Medical Consent: I give my consent to the person named above participating in the DofE Award. I have been informed of and have read the information relating to the activities. I have ensured that my child understands that it is important that for their own and the groups safety that any instructions given by staff must be complied with. I undertake to inform the staff of any changes in the health or medication of the person named above as and when necessary. I agree that staff from Creative International Adventures may, in the event of an emergency, give permission for the person named above to receive medical treatment * I agree Use of Mobile phones statement: I understand that the use of personal mobile phones on expeditions is not permitted. A group mobile phone will be provided for emergency use only to allow the group to contact the supervisor or emergency services. In the event of taking a personal mobile on expedition it is likely that my son/daughter will be deferred and have to complete an additional expedition. The additional costs associated with that are not covered in the expedition package, so to complete the expedition section I would have to pay for the extra expedition. * I agree Permission to leave before programmed finish time:Our session times are based on the normal time required to complete a set of tasks. In some instances students may complete all their required tasks before the published end of the session time. * I give my young person permission to leave before the published finish time, if they have completed all tasks and the instructor is happy for them to leave. My young person must wait with the instructor until the end of the session in all instances. Model release agreement: I give permission for any photographs or videos taken whilst involved in the activities to be used for promotional or presentation purposes. This may also be placed on the internet website. * I agree I disagree Signature * Draw It Type It Clear Kit & Equipment Hire Please let us know what equipment that you require to hire. If you already have the equipment please select the relevant box so that we know you will bring your own equipment to the sessions. Prices are £1/itemFees can be paid on the day. Walking Boots * Has own pair Size 2 Size 3 Size 4 Size 5 Size 6 Size 7 Size 8 Size 9 Size 10 Size 11 Size 12 Cost £1/day Waterproof Trousers * Has own pair XS Small Medium Large XL XXL Cost £1/day Waterproof Coat * Has own Waterproof XS Small Medium Large XL XXL Cost £1/day Hat & Gloves * Has own Hat & Gloves S/M M/L Cost £1/day Roll Mat * Has own Roll Mat Roll Mat Cost £1/day Sleeping Bag * Has own Sleeping Bag Sleeping Bag Cost £1/day Expedition Rucksack * Has own Rucksack Rucksack Cost £1/day 2 Strap Day Bag * Has own Daybag Daybag (no charge) Additional Comments/Feedback Use this box for questions, feedback or any additional information you would like us to know. Financial assistance/bursary request I do not require a form Please send me a bursary application form for my young person as they are disadvantaged either through finance or disability.