Hertfordshire Scouts Mountaineering Section Application Form

ApplicantInformation

Applicant’s Name:(BLOCK CAPITALS) / Date of Birth:
Home Address: / M/F
Post Code:
Tel Number: / Home: / Mobile:
Contact Email:
Group and Troop/ Unit:
Scout Membership numberand DBS number / Must have if applicant over 18 at time of course
Course Title: / IMC 2018– Lochearnhead Scout Station
Choose One Date: / Friday 30th March– Saturday7thApril 2018 / Friday6thApril – Saturday14th April 2018
Applicant Sign Off or Parent/Guardian (if applicant is under 18)
I hereby give responsibility for me/my son/my daughter to the course Instructors/Leaders/First Aiders, and authorise them to sign on my behalf any papers needed by the medical authorities in case of emergency hospital treatment if the delay to obtain a signature is considered inadvisable by the medical practitioner concerned. This includes authority to act in "Loco Parentis" particularly in regard to my son’s/my daughter’s participation in "Adventurous Activities".
I give permission for images of me/my son/my daughter to be used for promotional purposes within Scouting.
Signature:
Name:(BLOCK CAPITALS)
Leader Sign Off (not applicable to Network or Leader applicants)
I confirm that the applicant is a member of the Scout movement and I recommend that the applicant is suitable for this mountaineering course. (Please read the course outline). If in doubt please contact Andrew Rice
Signature:
Name:(BLOCK CAPITALS)
Position: / S.L / E.S.L / G.S.L / D.C. / D.M.A
Contact Email:

Applicant’s Next of Kin Information

Next of Kin Name:
(BLOCK CAPITALS)
Relationship:
Contact Address during the course:
Contact Email:
Contact Tel Number: / Home: / Mobile:
Applicant’s Medical History
NHS Number
Allergies:
Conditions:
Medication:
Other relevant information: / Please detail on separate sheet
Special Dietary Requirements
Tetanus: / Immunised in last 10 yr: Yes / No
Doctor’ s Name: / Tel. No:
Address:
Polo shirt size
Tick One / XS - 36 in / S - 38 in / M - 40 in / L - 42/44 in / XL - 46 in / XXL - 48 in

£75 deposit (non-refundable) must be enclosed with the application form.A balance of £200 will be payable at a later date.

The completed and signed form can be sent by post to Andrew Rice, 83 Homestead Road, Hatfield, Herts, AL10 0QR or scanned and emailed to .

The deposit can be paid by cheque addressed to “Hertfordshire Scouts - Mountain”or by bank transfer to Hertfordshire Scouts Mountain Sort Code 20-20-37 A/c No 10798444. Please put the Applicant Surname in the Reference section.

Tick one: / Cheque / Bank transfer

Any Queries please telephone01707 265255or