INDIVIDUAL BOOKING FORM—2017 The Duke of Edinburgh’s International Award Expeditions Personal Details FULL NAME: ______________________________________________ DATE OF BIRTH: __________________ MALE / FEMALE ADDRESS: __________________________________________________________________________________________________ SUBURB: ______________________________________________________ STATE: __________ POST CODE: ________________ PHONE: ______________________________________
EMAIL: ______________________________________________________________ FAX: __________________________________
Hike Information Which of our expeditions would you like to participate in: Activity Date: ________________________ Location of Activity: ______________________________________ Bronze Silver Gold
If you are qualifying, when and where was your practice hike? ____________________________________
Hike Prices/Hire Equipment BRONZE
$345.00 /Kosciuszko $730/NZ $2050
Trangia (Cooking Stove)
Tent (Two Person)
Sleeping Mat for Purchase
Compass for Purchase
Whistle for Purchase
TOTAL HIRE/PURCHASE COST
* An additional $10 is charged for any hike over a weekend, and $20 for any hike over a Public Holiday.
Payment Details Please find my full payment of $___________________ by cheque or money order. Cheques made payable to The Collaroy Centre. OR Please debit my credit card for the amount of $_____________________ being full payment. The transaction will appear on your bank statement as ‘Salvation Army Youth’ Name on Card: ________________________________________ Signature: _________________________________________ Visa
Expiry Date: _______ /_________ CCV: __ __ __
Office Use Only
EMERGENCY CONTACT 1:
EMERGENCY CONTACT 2:
HEALTH CARE CARD NO:
PRIVATE INSURANCE COVER PROVIDER:
HAVE YOU BEEN ON AN EXPEDITION WITH THE COLLAROY CENTRE PREVIOUSLY?
YES / NO (Please circle)
WOULD YOU LIKE TO RECEIVE INFORMATION ABOUT OUR UP AND COMING EXPEDITIONS VIA EMAIL? YES/NO (Please circle) HOW DID YOU HEAR ABOUT OUR EXPEDITIONS? ___________________________________________________________________________ IS THERE ANYONE ELSE ATTENDING YOUR HIKE THAT YOU WOULD LIKE TO BE GROUPED WITH? (This can not be guaranteed but we will do our best to ensure you are together). _________________________________________________________________________________________________________________________
Medical Information The following information will remain confidential: Are you currently taking any form of medication? Yes / No (please circle) If yes, please list and provide details of all medication including dosage, any side effects and reasons for taking medication: _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ Do you suffer from allergies/anaphylaxis? Yes / No (please circle) If yes, please give details including triggers, medication needed and severity. If anaphylaxis you must provide us with an ASCIA plan prior to hiking, and you are required to bring 2 adrenaline autoinjectors on your camp: _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ Do you suffer from Asthma? (please circle) Yes / No If yes, please give details including medication, triggers and frequency. If you have an Asthma Action Plan it must be given to us prior to hiking and you must bring all relevant medication with you: _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ Are there any other injuries or medical conditions that we need to be aware of? (for example: diabetes, heart and lung conditions, mental illness, back or joint problems, epilepsy, vision impairment). To help provide the best level of care, all conditions must be disclosed. _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ In what month and year did you last have a tetanus shot: ___________/____________ Please Note: All briefing sessions will be held at The Collaroy Centre located at the end of Homestead Ave, Collaroy. It is compulsory for students to attend a briefing prior to a practice hike. We will send you a booking confirmation, briefing details and itinerary once payment has been processed. This is included in hike cost.
For assessing, please email your activity summary to [email protected]
Our Instructors have signed the Duke of Ed Volunteer Code of Conduct form, and have completed a NSW Working With Children check.
Term and Conditions Late Booking Policy 1. A $25 late payment fee is incurred for all forms arriving at The Collaroy Centre after 4pm on the hike cut-off date advertised on our website. 2. A booking form is void if submitted after the briefing date advertised on our website. Cancellation Policy 1. If a booking is cancelled more than 2 weeks prior to the commencement date of the program, any fees paid may be refunded or transferred to the next holiday period. Extra charges will be incurred on a transfer if the course fees have increased since the initial booking. In addition, a $25 administration fee may be charged. 2. If a booking is cancelled less than 2 weeks prior to the commencement date of the program, any fees paid to The Collaroy Centre will be forfeited. 3. All cancellations require written notification to The Collaroy Centre via post, email or fax. Contact details are below acceptance. 4. If adverse weather or extenuating circumstances require The Collaroy Centre to cancel a program prior to it commencing, we will transfer or refund your booking. Discipline 1. The Collaroy Centre reserves the right to exclude any participant from continuing the program if, in the opinion of the instructor, terms and conditions (whether expressed or implied) have not been adhered to. 2. If a participant is excluded from the program, it is the responsibility of the person designated as the “emergency contact” on the participants booking form to provide transportation from, in the opinion of the Logistics person, the most convenient access point. Terms of Participation 1. Alcohol/Drugs – Under no circumstances is any alcohol or any non prescribed drug to be brought onto the program. 2. Smoking – Smoking is not permitted on The Collaroy Centre programs. 3. Flora & Fauna – The Collaroy Centre maintains a minimum environmental impact policy, thus flora and fauna must not be disturbed. 4. First Aid – Our staff possess current Remote Area First Aid qualifications, and will carry with them a first aid kit and administer first aid when required. In the event that a participant needs to be evacuated from the program for medical reasons, it is the responsibility of the person designated as the “emergency contact” on the participants booking information to provide transportation from, in the opinion of the Logistics person, the most convenient access point. The Collaroy Centre reserves the right to exclude a participant from a program if, in the opinion of the instructor, the health of the participant creates too great a risk of deterioration during the program. 5. Weather – The Collaroy Centre reserves the right to cancel, change, or postpone any program if, in the opinion of the Program Director, it is unsafe for the program to run. 6. Swimming - Swimming is not permitted on any of The Collaroy Centre Hikes Hire Equipment 1. Equipment must be paid for in full at the time of the booking. 2. Equipment will be available for pick up at the beginning of an expedition and collected at the end of an expedition. 3. Any lost or stolen equipment (including tent pegs) will be paid for in full by the hirer. 4. Any repairs to equipment beyond what is reasonable wear and tear will be paid for by the hirer. 5. Hire equipment cancellations require written confirmation and will not be refunded after the advertised briefing date. Risk Warning & Release Please read the following. If you have any questions regarding the risks associated with any of the activities you or your child will be participating in please contact The Collaroy Centre before signing. The Collaroy Centre is justifiably proud of its excellent safety record. We are committed to the continued development of our already excellent operating procedures to maintain this record and to manage, as much as possible, all risks inherent in any of our programs. All Recreational, Educational or Therapeutic Activities in which you or your child will be participating in during any course, expedition or program run by The Salvation Army Collaroy Youth and Community Centre (The Collaroy Centre) will involve some risk of injury or even death. Generally, these risks may include but are not limited to:* * * * * * * 1. 2. 3.
Exposure to dangerous weather conditions (extreme heat, extreme cold, storm activity) Falls (may be due to rough terrain or inexperience) Injuries to joints or back (may be from carrying heavy weight) Aggravation of existing medical conditions due to isolated environment or physical activity Burns (may be from cooking stoves or campfires) Injuries sustained due to equipment failure Drowning
I have read the preceding risk warning and accepted the risks involved in participating in all activities. I agree on behalf of myself and my heirs, executors, and assignees to release The Salvation Army Collaroy Youth and Community Centre and its servants and agents from all claims, actions, suits, and demands from loss or injury to myself or my dependents arising from participation in the activity. I agree to abide by all express or implied terms and conditions.
Disclaimer The applicant acknowledges that The Salvation Army and the Management of The Collaroy Centre will not be responsible for any loss or damage to any property brought on to the program. Should any claim be made for such loss or damage to property owned by any person associated with the applicant, or any person or body corporate associated with such person, then the applicant will indemnify The Salvation Army and the Management in respect of all such claims.
The Collaroy Centre PO Box 11 COLLAROY BEACH NSW 2097 Fax: (02) 9971 1895 Email: [email protected]