Application FORM

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Please complete all sections in BLOCK CAPITALS and send to the expedition leader, see webste for their address details, www.leadingedge.org.uk

Name of Expedition:

Section A. Details of Applicant:

Surname: First Name(s):
Address: Home Tel No:
 
 
  Post Code:
Date of Birth: Email address:
Age in years on date of Expedition departure:  
Nationality: Passport No:

Occupation:
If student School/College name:
Course being undertaken: Full or Part-time ?
Employer's name:
Address:
 
  Post Code:

Next of Kin, name: Relationship to you:
Address: Home Tel No:
 
 
  Post Code:

Can you swim 500 metres ?
Have you had any previous expedition experience ?
If so, please give details:
 
Courses taken/Qualifications held ?
 
Do you/have you belonged to any group (eg. Scouts, guides, cadets)
Do you hold a full driving licence ?
Can you speak any foreign languages ? (give details):
Do you have any first aid experience ?
Do you play any musical instruments ?
What are your hobbies & interests ?
Additional information ?
 

Section B. Medical Details:

What is your present weight ? and height ?
Do you have any special dietary requirements?

Have you ever suffered from any of the following ? answer YES or NO If yes to any of the below please explain on a separate sheet of A4 paper. Insurance cover can depend on full disclosure.
High blood pressure? Asthma?
Diabetes? Allergies?
Gastric/Peptic ulcers? Migraines?
Grumbling appendix? Joint pains?
Epilepsy, fits or blackouts?
Have you ever had ?
A serious injury? A serious disease?
To wear glasses?
Do you now ?
Take any medication? Smoke?
Are there any problems we should be aware of?  
 

Medical Declaration:

Failure to disclose any pre-existing medical condition may invalidate your Insurance.

I certify that I have fully answered all the questions and that the information given is true.
I understand that I may be required to attend a medical examination with my own doctor.

Signature of
applicant:		  

(For Parent / Guardian to sign if applicant is under 18 years of age)
I have read the Medical Declaration above and confirm the answers and information given.

Signature of
Parent/Guardian:		  

Section C, Parental Consent: (required if applicant is under 18 years of age.)

I have read the expedition description and the medical declaration and I wish
____________________ (name of applicant), to be considered for
____________________ (name of expedition).

I hereby give my consent for ____________________ (name of applicant),
to participate in all necessary selection, training and to attend the expedition.

Signature of
Parent/Guardian:		  
Date:  

Section D, Dorset Expeditionary Society Disclaimer:

The Society and its members do not control the conduct of any expedition in any way at all. This is the responsibility of the expedition leader as an individual and he/she will arrange such insurance cover for accidental injury, loss of belongings etc. as he/she thinks appropriate. It is up to you to ensure that such cover satisfies all your needs, or you can arrange your own additional cover at your own expense if you wish.

The Society and its members do not accept responsibility or liability of any kind whether for personal accident or injury or loss of belongings at any point of the expedition including training and other activities prior to departure and transport within the U.K. or abroad.

For the avoidance of doubt the Society and its members as such are not parties to the expedition and do not carry insurance of that kind.

I have read and understand the above statement

Signature of
applicant:		  
Date:  

(& if applicant is under 18 years of age :-)

Signature of
Parent/Guardian:		  
Date:  

 

Section E, Enclosures:

I enclose the following :-

a) A deposit cheque to the value of £50 (see notes on front cover of this form)

b) Passport-size photos

Section F.

Please tell us how you heard about this expedition:-

School/Teacher: Magazine, (which one?):
Word of mouth/Friend: Poster, (where?):

Did you contact the DES office for an information pack? (yes/no):

Other, (please specify):

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This page was last modified on December 01, 2008.