SECTION 2: Participant Medical and Emergency Information

Transcription

1 The Gap Year Experience Course Registration Form SECTION 1: Participant Information Full Name: ID Number: Cell Number: Home Number: Address: Residential Address: CODE: Postal Address (If different) CODE: *Note Transport is not included in the course fees and there are regular offsite visits what will your mode of transport be? SECTION 2: Participant Medical and Emergency Information Doctor Name: Doctor Contact Number: Medical Aid (Yes/No) Medical Aid Number: Emergency Contact 1 Name: Relationship: Contact Number 1: Contact Number 2:

2 Emergency Contact 2 Name: Relationship: Contact Number 1: Contact Number 2: Do you have any allergies? Do you have any significant medical condition? Is there any other important information we should be aware of? SECTION 3: Parent / Guardian Information Full name: ID Number: Cell Number: Work Number: Home Number: Parent / Guardian 1 Parent / Guardian 2 Home Address: Postal Address:

3 SECTION 4: Course Payment & Optional Extras a) Course length option - Tick which course option you are registering for. Full year 29 th Jan to 30 th Nov 2018 Semester 1 only 29 th Jan to 22 nd Jun 2018 Semester 2 only 16 th Jul to 30 th Nov 2018 b) Optional extras Which course optional extras (not included in fee payment) would you potentially be interested in partaking? Prices are estimations. Semester 1: One-day Game Reserve Visit (Gauteng) Overnight Cape Town Visit (Including flights, transport & Accommodation) = +/- R500 = +/- R4000 Semester 2: Magix Movie Editor Pro Programme = +/- R1 000 Corel Draw Programme (Student Suite) = +/- R1 000 One day Durban Trip (Including Flights, Transport, Ushaka Land Fee) = +/- R2 500

4 C) Payment Options FULL YEAR PAYMENT OPTIONS Full Payment Due Date 15 th Dec th Feb th Apr th Apr 2018 Payment Details Early Bird Option 1 - R deposit Due by 30 Sep R Full Payment Due by 15 th Dec 2017; - (R5 000 discount) Total payment R Early Bird Option 2 - R deposit due by 30 Sep R Full Payment Due by 28 th Feb 2018; - (R2 500 Discount) Total payment = R Payment Plan 1 Payment of R8 000 per month - First Monthly Payment on the 31 st Oct 2017 and; - Last Payment will be on the 30 th Apr 2018 Total Payment = R Payment Plan 2 - Deposit Due by 30 th Sep R (50% of full payment) due by 26 th Jan R (Full payment) due by 30 th Apr 2018 Total Payment = R Tick

5 SEMESTER PAYMENT OPTIONS Full Payment Due Date 15 th Dec th Feb th Apr th Apr 2018 Semester 1 (29 JANUARY 22 JUNE 2018) Payment Details Early Bird Option 1 - R Full Payment Due by 15 th Dec (R3 000 Discount) Total payment = R37000 Early Bird Option 2 - R Due (R of total) due by 26 th Jan R Last payment due by 28 th Feb (R1 500 Discount) Total payment = R Payment Plan 1 Monthly Payment of R4 285 per month - First Monthly Payment on the 31 st Oct 2017 and; - Last Payment will be on the 30 th Apr 2018 Total Payment = R Payment Plan 2 - R Due (R of total) due by 26 th Jan R Last payment due by 30 th Apr 2018 Total Payment = R Tick

6 Full Payment Due Date 31 st Mar st Aug st Oct th Sep 2018 Semester 2 (16 JULY 30 NOVEMBER 2018) Payment Details Early Bird Option 1 - R deposit Due by 28 th Feb R Full Payment Due by 31 st Mar (R3 000 discount) Total payment = R37000 Early Bird Option 2 - R deposit due by 31 st Mar R % Payment due by 13 th Jul R last payment due by 31 st Aug (R1 500 Discount) Total payment = R Payment Plan 1 - R deposit due by 31 st Mar 2018 Payment of R4 285 per month - First Monthly Payment on the 30 th Apr 2018 and; - Last Payment will be on the 31 st Oct 2018 Total Payment = R Payment Plan 2 - R deposit due by 31 st Mar R (R of total) due by 13 th Jul R Last payment due by 30 th Sep 2018 Total Payment = R Tick Gap year banking details: Bank: FNB Account type: gold business account Account number: Branch: ROSEBANK (253305) (Please use participant s name as the reference) Please proof of payments to info@gapyearcourse.co.za

7 SECTION 4: Declaration by Applicant and Parent / Guardian a) Declaration by participant I (participants NAME) Agree to: 1. Abide by the rules of the gap year experience 2. I hold myself responsible for the payment of all fees and charges due and payable by me to the gap year experience; any arrears and interest on arrears; and any costs of recovery including attorney fees. If I do not inform the gap year experience in writing of withdrawal from the course without a 3 month notice I will be liable for full fees even if I do not attend course dates. 3. I waive all claims against the gap year course and its teachers / facilitators / venue employees for: any damage or loss suffered while I am, or as a consequence of my being, a gap year participant and/or arising out of loss or destruction of, or damage to, any property belonging to me or any other person 4. I will conduct myself in a passionate, punctual, flexible and courteous way with Gap year teachers, other participants, guest lecturers and members of the public. 5. I have / will arrange my own transport for both on-site and off-site visits 6. Whilst every effort will be made by the gap year experience team to ensure that every skill / job experience / topic listed on the course outline is dealt with, there may be a few we don t get to due to time constraints or availability. We may also include alternate skills / job experiences / topics from time to time. 7. From time to time there may be extra costs for events, outings or materials not included herein that may occur during the year 8. If I am a minor (under 18 years of age), I have the consent of my parent(s) / guardian to sign this form 9. The information given on this form is completely accurate Signature of Participant: Date:

8 b) Declaration and suretyship by parent or legal guardian If you are under 18 years of age, your parent / legal guardian must make this declaration. If you are 18 or older and your parent / legal guardian will be paying your fees, your parent / legal guardian must make this declaration: I, (Parent s / guardian s name): (ID Number): Parent / guardian of (participant s name): Agree and consent to the above declaration, undertakings, waiver and indemnity by the participant. I consent to the participant signing indemnity forms on my behalf. I hold myself jointly liable with the participant as co-debtor for all amounts due by the participant to the gap year experience, until I notify the gap year experience to the contrary, in which event a 3 month notice period must be given. Date: Signature: