Registration Forms. Salkantay Inca Trail Challenge COMPLETE YOUR CHALLENGE OF A LIFETIME AND HELP OTHERS TO FACE THEIR PERSONAL CHALLENGES
|
|
- Osborne Dennis
- 6 years ago
- Views:
Transcription
1 Registered Charity No Registration Forms Salkantay Inca Trail Challenge Saturday 26 th July Tuesday 5 th August 2014 COMPLETE YOUR CHALLENGE OF A LIFETIME AND HELP OTHERS TO FACE THEIR PERSONAL CHALLENGES For further information please contact or fundraising@compton-hospice.org.uk Fundraising Department, Compton Hospice, The Cedars, 39 Compton Road West, Wolverhampton, WV3 9DW Compton Hospice is a registered charity - number Tour operated by Different Travel ATOL 6706
2 Contents: Salkantay Inca Trail Challenge 2014 Compton Hospice Cover Form page 1 Terms & Conditions page 2 Registration Form pages 3-4 Medical Form pages 5-6
3 Name. Compton Hospice Salkantay Inca Trail Challenge 26 th July 5 th August 2014 I wish to register for a place on the Compton Hospice Salkantay Inca Trail Challenge Please find enclosed: 1. Completed registration form 2. Completed medical questionnaire 3. A photocopy of passport 4. A copy of insurance certificate & policy wording doc where it stipulates cover for guided trekking at the altitude required for the trek (only if you haven t used Campbell Irvine s Different Travel Policy) non-refundable deposit. (Please make cheques payable to Compton Hospice) I agree that I will pay Compton Hospice a total of 3850, no later than 3 months after returning from the Salkantay Inca Trail Challenge This is broken down as follows: 250 deposit (enclosed) 2300 to be paid 12 weeks prior to departure (3 rd May 2014) 1300 Balance to be paid no later than 3 months after return (5 th November 2014) Compton Hospice confirms that money can be paid in at any time and in any amount up to the above mentioned timelines. A receipt will be issued for all monies received. DECLARATION **I agree to the terms and conditions stated overleaf** ** I understand that single and group photographs may be taken of me at Compton events and I am happy for any photographs to be used for Compton Hospice marketing and future publications** Signed Date.. Please return completed registration pack to: Fundraising Department, Compton Hospice, The Cedars, 39 Compton Road West, Wolverhampton, WV3 9DW 1
4 Terms and Conditions 1. Overseas Challenge Agreement This terms and conditions set out below will form the basis of your relationship with Compton Hospice. Please read it carefully as it sets out your respective rights and obligations. All bookings are subject to the following terms and conditions. 2. Who organises the trip? Different Travel is the organiser of the trip on behalf of Compton Hospice. 3. Itinerary and Timetable Sometimes situations are out of human control, so Compton Hospice and Different Travel reserve the right to change the itinerary, times and locations should the need arise. 4. What is the payment timetable? 4.1 You must pay the non refundable deposit at time of booking. 4.2 The tour cost payment must be paid at least 12 weeks prior to departure. 4.3 The remaining sponsorship money must be paid within 3 months after the trip. All payment prices are shown on the Compton Hospice registration form overleaf. 6. What happens if I do not pay on time? If Compton Hospice do not receive all payments in full and on time you place on the trip may no longer be guaranteed. Compton Hospice will endeavour to give you advice on how to reach your payments but if it is deemed that you are not able to continue Compton hospice will treat your place as a participant cancellation. 7. Cancellation Schedule 5.1 Cancellation by you can be made by you at NO COST up to 11 months before departure, however to refund sponsor money already paid to us we will require a written refund request from the donor accompanied by proof of the donation. 5.2 Cancellation by you between 11 and 3 months loss of deposit only, however to refund sponsor money already paid to us we will require a written refund request from the donor accompanied by proof of the donation. 5.3 Cancellation by you within 3 months of travel full payment is required We reserve the right to cancel the trip at any time leading up to date of departure. It is very rare that this will happen, however if it does then we will offer you an alternative Open Challenge, if this is not acceptable we will refund your deposit and sponsorship money on written request from the donors. 8. Do I need travel Insurance? Travel insurance, including cover for baggage, is mandatory for all participants. It is your responsibility to ensure that you have adequate cover for the duration of the trip. If it is found that you do not have sufficient cover you may not be permitted to continue, with no right of refund. If you take out Different Travel s specially arranged insurance with Campbell Irvine it is your responsibility to ensure that you receive all documentation. All participants are personally responsible for informing insurance companies of any pre-existing conditions. Any claims should be dealt directly with Campbell Irvine. Should you wish to source your own insurance you are responsible for ensuring that you have adequate cover for the duration of the trip. This must include cover for guided trekking and cover for any altitude that you may reach on the trek. You must also ensure that there are no exclusion clauses limiting protection for the type of activities included in the tour. It is your responsibility to provide Compton Hospice with a copy of your policy. 2
5 Compton Hospice Salkantay Inca Trail Challenge 26 th July 5 th August Personal Details Different Travel Registration Form Please complete all sections of this form in block capitals Title. Forename... Surname.. Name by which you like to be called. Address.. County Postcode. Date of birth.. Occupation... Home Tel... Work Tel.. Mobile. Please circle Gender M / F T-Shirt Size S M L XL 2. Dietary Requirements Do you have any special dietary requirements / food allergies? Y / N Vegetarian.. Vegan.. Vegan.. Nut Allergy.. Other Passport Details (please enclose a copy of your passport) Name as it appears on passport. Date of Birth. Passport No.. Place of Birth Nationality..... Issue Date....Expiry Date... Occupation Marital Status Please note that your passport must be valid until six months after the end of the event. 3
6 4. Next of Kin / Emergency Contact Please give details of the person you would like us to contact in case of an emergency. This should not be someone who will be on the challenge with you. Name.. Relationship Address.. Postcode Daytime Tel.. Evening Tel... Mobile Tel Travel insurance Details Name of your Travel insurance Provider.. Travel insurance Policy No.. Insurance 24hr Emergency Contact No (for use overseas) ** Important - If you are not using our insurance provider, please attach a copy of your insurance certificate and policy wording doc where it stipulates cover for guided trekking at the altitude required for the trek** Campbell Irvine policies have been specifically designed to cover unique trips. They offer a comprehensive volunteer travel insurance policy which provides the necessary cover by Campbell Irvine and is underwritten by AXA Insurance (UK) PLC. 24-hour Worldwide Emergency Medical Service is supplied, and you are automatically covered for activities such as manual work, trekking, extreme sports and - should you want to - even bungee jumping! For further details contact Campbell Irvine direct on and request a quote for a 'Different Travel Company' policy or refer to their website 6. Accommodation Accommodation will be shared and can consist of twin-bedded or multi-bedded, single and/or mixed gender rooms/tents. Please let us know if there is somebody else on the trip you would like to share with. We will try to accommodate your request, however it is not guaranteed. Share with. 7. Declaration and Registration I confirm that all of the information provided by me on this form is to the best of my knowledge true and correct. I understand that if any of the information provided by me on the form is found to be false, I risk losing my place on the challenge. I understand that travel insurance is required for this event and that it is my responsibility to ensure that I have adequate medical insurance cover for this event. I understand that single and group photos may be taken of me during the challenge and I am happy for any photographs to be used for Compton Hospice marketing and future publications. Signed.. Date. 4
7 Different Travel LTD MEDICAL QUESTIONNAIRE Compton Hospice Salkantay Inca Trail Challenge 26 th July 5 th August 2014 (In confidence when complete) It is for your own safety that we find out as much as possible about your medical history, to ensure that you can cope with the demands of the trip safely and without risk to your health. Your answers will be treated in the strictest confidence and will not necessarily adversely affect your chance to take part. Any decisions will be made in consultation with you. The information you supply will only be disclosed to Different Travel Ltd, Compton Hospice and medical staff employed by the tour operator for the event. It is one of the conditions of your registration that you give full and accurate details. Please complete clearly in BLOCK CAPITALS A. PERSONAL DETAILS NAME:.... TEL NO: DATE OF BIRTH:... AGE ON TRIP: HEIGHT:... WEIGHT:.. B. MEDICAL HISTORY 1. Please state whether you suffer from or have ever suffered from any of the following conditions: (please tick) 1/ Raised or low blood pressure? 2/ Heart or circulatory disease? 3/ Epilepsy, seizures, convulsions? 4/ Psychiatric/mental illness/depression? 5/ Chest or lung disease? 6/ Vertigo / Ménieres disease? 7/ Diabetes? 8/ Joint or back injuries/problems? 9/ Allergies (e.g. hayfever, dietary, drugs, animals etc)? 10/ Asthma, wheezing and/or shortness of breath? 11/ Digestive or bowel disorders? 12/ Cerebral disease?(e.g. stroke, head injuries etc) 13/ Fractures, tendon, ligament/cartilage damage? 14/ Surgical operations in last 2 years? 15/ Haematological or blood disorders? 16/ Metabolic or endocrinal disorders? 17/ Are you pregnant? 18/ Physical disability, mobility or other disabilities? 19/ Carrier of infectious diseases? 20/ Migraine? 21/ Hospitalised in last 2 years? 22/ Registered disabled? 23/ Obesity (BMI of 30 or above)? 24/ Fainting or blackouts? 25/ Are you awaiting surgery/tests/investigations? 26/ Any illness or conditions not already mentioned? 2. If you have answered yes to any questions above, please give further details below or on a separate sheet: Do you regularly and/or currently use any form of medication? YES/NO (please circle) If so please give details: 4. Do you have any specific dietary requirements? YES/NO (please circle) If so, please give details below: Have you ever suffered from asthma? YES/NO (please circle) If so, a) When was the last time you needed hospital treatment? b) When was the last time you needed steroid tablets?.... c) What medication/inhalers do you use? Please specify any phobias you may have (e.g. flying/heights) Please give details if ever suffered from altitude sickness
8 IMPORTANT PLEASE READ CAREFULLY BEFORE SIGNING In the event of an accident or illness whilst on the trip, I hereby give permission for Different Travel Ltd. to initiate medical treatment and to inform my next of kin/emergency contact (as detailed on my application form) if appropriate. To the best of my knowledge I confirm that my mental and physical health and fitness is good and that the information I have provided in this questionnaire is a true and accurate description of my medical history and current condition. I understand that by giving false information I endanger both my own safety and that of others on the trip. I agree to take with me sufficient supplies of medication needed for my current medical condition and for any condition which I have had previously which may reasonably be expected to re-occur. I agree that Different Travel Ltd. or medical staff employed by them may approach my GP to verify the information on this form and attain some further details as they think necessary and that my GP may release such information to them. I understand that Different Travel Ltd. cannot accept any liability or expenses resulting from any illness, injury or other untoward occurrence arising from any undisclosed medical condition (other than to the extent that death or personal injury arises as a result of its negligence). I also understand that failure to disclose a pre-existing medical condition could invalidate my travel insurance and that I am responsible for declaring any pre-existing medical conditions directly to my insurance company prior to departure. I confirm that I will immediately inform Different Travel Ltd. of any change to the information I have provided on this medical questionnaire. SIGNED:. DATE:... RETURNING THIS MEDICAL FORM IS PART OF YOUR REGISTRATION. This section only needs to be completed if you are over 65 OR have answered YES to any of the questions OR have ticked any of the boxes on the medical form:- MEDICAL FORM TO BE COMPLETED BY THE FAMILY DOCTOR/PHYSICIAN WHO HAS ACCESS TO THE PATIENT S MEDICAL HISTORY. The person named overleaf will be participating in a charity fundraising trek of 10 days duration, during which time he/she will be subject to basic camping and living conditions. The demands in more detail will involve trekking and working for up to 8-10 hours per day for 4 days over some rough terrain and involving extremes of temperatures and climate, and altitudes up to 4,600m. Participants will be staying in tents. Some food may be cooked on gas burners. Different Travel Ltd will provide a tour leader for each trip to give immediate first aid and ensure high hygiene standards are taught and maintained. The event may be a considerable distance from any hospital back up. With the above information, if there is any matter of which you feel that Different Travel Ltd should be aware, please supply details on a separate sheet. If you require any further details please call Different Travel Ltd on or info@different-travel.com.. I have read the above paragraph and agree that the participant s medical details are correct. In my opinion this patient is currently fit and healthy both mentally and physically, and able to participate in the event. Doctor s Signature: Date:... Doctor s Name (Block Capitals Please)... Address:. DOCTORS STAMP & GMC NUMBER 6
Dove House Hospice Indian Himalayas Trek & Project 26 th April 6 th May 2014
Dove House Hospice Indian Himalayas Trek & Project 26 th April 6 th May 2014 Please return this completed form, along with your cheque (if applicable) and passport copy to: Becky Baynes, Dove House Hospice,
More informationYour Details (please complete your name exactly as it appears on the passport you will travel with)
St. Margaret s Hospice - Machu Picchu Trek & Community Project 1 st 10 th April 2017 Please return this completed form, along with your cheque (if applicable) and passport copy to: Sonia Bateman, St. Margaret
More informationSt Richard s Hospice Nepal Himalaya Trek and Hospice Project 2 nd 13 th November 2019
St Richard s Hospice Nepal Himalaya Trek and Hospice Project 2 nd 13 th November 2019 Please return this completed form, along with your cheque (if applicable) and passport copy to: Fundraising, St Richard's
More informationDove House Hospice Trek Vietnam 27 th April 7 th May 2019
Dove House Hospice Trek Vietnam 27 th April 7 th May 2019 Please return this completed form, along with your cheque (if applicable) and passport copy to: The Fundraising Team, Dove House Hospice, Chamberlain
More informationCats Protection Himalayan trek and tiger conservation experience 7 19 October 2017
Cats Protection Himalayan trek and tiger conservation experience 7 19 October 2017 Please return this completed form, along with your cheque (if applicable) and passport copy to: The Different Travel Company,
More informationPlease complete the form below in BLOCK CAPITALS
St Oswald s Hospice Sahara Challenge (3 rd 10 th November 2018) Registration Form Registration Fee: 275 payable upon booking Minimum sponsorship: 2,750 payable to St Oswald s Hospice Please complete this
More informationVive Le Vélo Champagne Cycle Tour May 2017
Vive Le Vélo Champagne Cycle Tour 10 14 May 2017 Please return this completed form, along with your cheque/payment confirmation for 75 and passport copy to: The A-T Society, Rothamsted, Harpenden, Hertfordshire,
More informationJoin us in Chamonix for a ski experience like no other!
MS Trust Monster Ski 2014 Join us in Chamonix for a ski experience like no other! Thank you for your interest in Monster Ski, the MS Trust s ski & snowboard challenge, which will take place in Chamonix,
More informationRegistration Form Trek Jordan 2019
Please return your completed, signed form to JCH along with your deposit in order to confirm your place on the trek. Trip: TREKS- Jordan Trip Date: 5 th -12 th October 2019 All information must be as per
More informationisyllabus Umrah Application Form isyllabus Umrah with Shaykh Amer Jamil Application Form
Umrah isyllabus with Shaykh Amer Jamil Application Form iumrah@isyllabus.org.uk isyllabus Umrah 2014 And perform the Hajj and Umrah in honour of God [2:196] Introduction isyllabus is taking you on an unforgettable
More informationPeru Hiking Challenge 4 13 May 2013 Registration form
Peru Hiking Challenge 4 13 May 2013 Registration form Please read and complete all sections of this form and return to: Challenge Team, Macmillan Cancer Support, 89 Albert Embankment, London SE1 7UQ Fax:
More informationCassis to Monaco Participant Registration Form 5 7 October 2018
Cassis to Monaco Participant Registration Form 5 7 October 2018 Participation in the Cassis to Monaco cycle includes: Twin share hotel accommodation on the evenings of 5 th to 7 th October 2018. Single
More informationEQ TRAVEL CLAIM FORM
EQ TRAVEL CLAIM FORM Agency Policy No Please note: Sections 1, 2 and 12 must be completed. Sections 3 to 11 complete only the relevant sections. The acceptance of this form is NOT an admission of liability
More informationStand Up On Everest. Telephone Address I do not want any of my contact details passed on
Please read and complete all sections of this form and return to: or email jeremy@standuponeverest.co.uk If you have any questions do not hesitate to call Jeremy on 07713904025 Registration information
More informationClimb Up So Kids Can Grow Up
Climb Up So Kids Can Grow Up Inca Trail Peru General Information Adventure Information Trip Name Start Date Applicant Information Full Name Preferred Name Address City State/Province Zip /Postal Code Country
More informationCLAIM FORM FREQUENTLY ASKED QUESTIONS
CLAIM FORM FREQUENTLY ASKED QUESTIONS Q: How long will it take for me to receive a response to my claim? A: We are committed to provide a quality service, our claims team will review the documentation
More informationAny questions, call
Any questions, call 020 7424 5522 Ok, I m interested in being a Santa skydiver but what exactly is a tandem skydive? A tandem skydive is the most popular and frequently chosen type of jump by novice and
More informationLONDON / CALAIS TO CHAMPAGNE BIKE RIDE REGISTRATION FORM
LONDON / CALAIS TO CHAMPAGNE BIKE RIDE REGISTRATION FORM Please read and complete all sections of the Registration Form and return along with the non refundable Registration Fee of 350 to: Rebecca Malcolm,
More informationMedical Emergency and Associated Expenses
TRAVEL INSURANCE CLAIM FORM Medical Emergency and Associated Expenses You must register any claim within 30 days of completion of your travel. Please supply original documents of the evidence you intend
More informationSkydive Cambridgeshire 2018 Terms & Conditions
Skydive Cambridgeshire 2018 Terms & Conditions The skydive is promoted by Parkinson s UK, a charity registered in England and Wales No. 258197 and in Scotland No. SC037554. The skydive is organised in
More informationRYLA 2017 Application Form District 9455
Participant Personal Details Surname: * Given Names: * Name for Badge: Gender: Date of Birth: / / Age at camp start: Address: Postcode: Home Phone: ( ) Mobile No.: * Preferred Number (Please circle): Email:
More informationCANCELLATION BEFORE DEPARTURE OF A TRIP
CA CANCELLATION BEFORE DEPARTURE OF A TRIP Travel Claims Facilities PO Box 395 Monks Green Farm Mangrove Lane Hertford SG13 9JW Email: claims@tif-plc.co.uk Web: www.tifgroup.co.uk Dear Customer, In order
More informationAny fee charged by the member s GP for providing information for completion of the claim form will not be covered.
TRAVEL COVER CLAIM FORM FILLING IN THIS FORM Please fill in this form if a claim is being made from the Worldwide Travel Cover. Complete this form in black ink and as fully and truthfully as possible.
More informationOCA Skydive Day. Take Off and Take Action. Enquiry Pack
OCA Skydive Day Take Off and Take Action Enquiry Pack OCA Skydive Day 5 th September 2015 Thank you for enquiring about the OCA Skydive Day On 5 th September 20 jumpers will participate in the challenge
More informationColorado Trek Paper Work Check List
Colorado Trek Paper Work Check List Please make sure you have all your paperwork before sending it in Due June 2 - Paperwork Due June 2 - Full payment of $2400 NAME HATS Release Form Adventure Experience
More informationThe Life Protector Plan
The Life Protector Plan Application for Assurance Life Protector (an Annually Renewable Life assurance) pays a lump sum in the event of death by natural or accidental cause. Policy carries a five year
More informationTHE NEW INDIA ASSURANCE CO. LTD.
THE NEW INDIA ASSURANCE CO. LTD. Regd. & Head Office: New India Assurance Bldg., 87, Mahatma Gandhi Road, Fort, Mumbai - 400 001. CLAIM FORM FOR OVERSEAS MEDICLAIM POLICY (To be submitted at the nearest
More informationSaturday June 8th 2013
Saturday June 8th 2013 What kind of skydive will I be doing? A Tandem skydive allows you to enjoy one minute of adrenaline-fuelled freefall from 13,500 feet harnessed to a BPA-qualified instructor; you
More informationCHANGING LIVES THROUGH LIFE-CHANGING EVENTS SAHARA DUNES TREK 2018
CHANGING LIVES THROUGH LIFE-CHANGING EVENTS SAHARA DUNES TREK 2018 START YOUR ADVENTURE HERE Siobhan & Dominic ABOUT THE CHALLENGE HANNAH S GUIDE TO THE SAHARA BOOK NOW ITINERARY KEY FACTS BOOK NOW FUNDING
More informationPRE-EXISTING MEDICAL DECLARATION FORM
PRE-EXISTING MEDICAL DECLARATION FORM This form is for customers who reside in New Zealand and wish to be assessed for pre-existing medical conditions. Please return a signed copy to info@tinz.co.nz At
More informationEmployed Disability (Accident or Sickness) Claim Form
Employed Disability (Accident or Sickness) Claim Form Section A Your details (To be completed by you) Title Surname Forename(s) Address Home Telephone Number Alternative Telephone Number Email Address
More informationTRAVEL CLASSIC INSURANCE CLAIM FORM. Geographical Limits : Asia Excl Worldwide Excl. Worldwide Incl Japan USA & CANADA USA & CANADA Hongkong
TRAVEL CLASSIC INSURANCE CLAIM FORM Claim No. Name of Person Claiming : Mr Mrs Miss Occupation : Day Time Tel No. DETAILS OF CERTIFICATE Policy No. : Travel Agent s Ref No. : Date Policy Issued : Date
More informationALL THAT S LEFT TO DO NOW IS TAKE THE LEAP!
A tandem skydive is the most popular and frequently chosen type of jump by novice and first time thrill-seekers you don t need any previous experience at all to do this jump! For this particular skydive
More informationCURTAILMENT OF A TRIP
C CURTAILMENT OF A TRIP Travel Claims Facilities PO Box 395 Monks Green Farm Mangrove Lane Hertford SG13 9JW Email: claims@tifgroup.co.uk Web: www.tifgroup.co.uk/services/claims Dear Customer, In order
More informationBrighter Futures Fundraising Department Trust HQ The Great Western Hospital Marlborough Road Swindon SN3 6BB
Brighter Futures Fundraising Department Trust HQ The Great Western Hospital Marlborough Road Swindon SN3 6BB Tel: 01793 605631 Email: Jennifer.Green@gwh.nhs.uk www.gwh.nhs.uk Registered Charity No: 1050892
More informationMedical Emergency and Associated Expenses
TRAVEL INSURANCE CLAIM FORM Medical Emergency and Associated Expenses You must register any claim within 30 days of completion of your travel. Please supply original documents of the evidence you intend
More informationCURTAILMENT OF A TRIP
C CURTAILMENT OF A TRIP Travel Claims Facilities 1 Tower View Kings Hill, West Malling Kent ME19 4UY Email: claims@tif-plc.co.uk Web: www.tifgroup.co.uk Dear Customer, In order that we can process your
More information2018 CENTRAL WASHINGTON UNIVERSITY MEN S RUGBY ELITE PROSPECT CAMP
2018 CENTRAL WASHINGTON UNIVERSITY MEN S RUGBY ELITE PROSPECT CAMP SAT., MAY 26 8 a.m. 4 p.m. Todd Thornley CONTACT PHONE: 509-963-2312 E-MAIL: todd.thornley@cwu.edu REGISTRATION DUE FRIDAY, MAY 18, 2018
More informationJump 10,000 ft for St Richard s Hospice
Jump 10,000 ft for St Richard s Hospice What's it like? Imagine standing at the edge of an open doorway in an aircraft flying at 10,000 feet - the noise of the engines and the wind ringing in your ears
More informationSwahili Safari Adventure
Swahili Safari Adventure With Sue Verrall 7 June 2019 BOOKING FORM Please read our terms and conditions on the reverse of this booking form before completing the form below. PERSONAL DETAILS: You Travelling
More informationCLAIM FORM FREQUENTLY ASKED QUESTIONS
CLAIM FORM FREQUENTLY ASKED QUESTIONS Q: How long will it take for me to receive a response to my claim? A: We are committed to provide a quality service, our claims team will review the documentation
More informationPersonal Medical Record
Personal Medical Record Personal details Age: Height (in meters): Weight (in kgs): BMI (kgs/metres 2 ): *Online BMI calculation tools are easily available 1. Any previous illness - past 3 months (mention
More informationWhat's it like? What does the jump involve? Points to remember:
What's it like? Imagine standing at the edge of an open doorway in an aircraft flying at 10,000 feet - the noise of the engines and the wind ringing in your ears with only the outline of distant fields
More informationTitle Mr Mrs Ms Miss Other Gender: Male Female. Mobile No. Date of Birth Day Month Year. Suburb/Town State Postcode
LEARNING ABROAD SHORT TERM PROGRAM STUDENT APPLICATION AND UNIT ENROLMENT FORM Note: Mac users open this document in Adobe Reader as 'preview software' is not compatible. Please contact ITSC on 6000 or
More informationAmerican Express Cardmember / Business Travel
American Express Cardmember / Business Travel Claim Form The information requested and supporting documents required for your claim are detailed below each section. Further documents or information may
More informationBe A Paleontologist For A Week!
Be A Paleontologist For A Week! Join Science Center staff as we trek to eastern Montana to experience life as a paleontologist! During the week you will prospect for fossils of both dinosaurs and other
More informationPolicy Application Individual and Family
Policy Application Individual and Family Important note about filling in this form: The answers you give to the questions contained in this Application will form the basis of any insurance policy issued,
More informationDear Thrill Seeker, Good luck with raising your sponsorship and we look forward to hearing from you soon. Yours sincerely
Dear Thrill Seeker, We are looking for people from all over the country to make a sponsored 10,000 feet freefall parachute jump on our behalf and in return we are willing to pay for it! Everything you
More informationSkydive. Have you got what it takes? Information Pack. Interested? Read on! In association with.
Information Pack Skydive Have you got what it takes? Exhilarating 10,000 foot freefall parachute jump No experience required If you raise the minimum sponsorship of 395 you will get to jump for free! Interested?
More informationSingle Trip & Annual Multi Trip
1. Which countries can I travel to with your insurance? Our geographical limits are: Single Trip & Annual Multi Trip Abo ut Buying a Policy Europe: Republic of Ireland, t h e C h a n n e l I s l a n d
More informationOverseas Secondment. Claim Form. Important Notes
Overseas Secondment Claim Form Important Notes To facilitate the processing of your claim, you are required to complete Sections A, B and C for all claim submissions. The issue and acceptance of this form
More informationWork Phone. Mobile / / Policy Number Date Issued Number of Travellers. Date of Booking Departure Date Return Date Total Days
Travel Insurance Claim Form Cancellation You must register any claim within 30 days of completion of your travel. Please supply original documents of the evidence you intend to rely on for your claim,
More informationPART 2: Payer s Details PLEASE COMPLETE ALL FIELDS IN BLOCK LETTERS
STUDENT PICTURE CONTACT DETAILS PART 1: Student Details PLEASE COMPLETE ALL FIELDS IN BLOCK LETTERS NB: Full time and Part Time Students to fill in Part 1,2,3,4,5 NB: E-Learning Students to fill in Part
More informationMake an exhilarating 10,000ft tandem skydive for Acorns Children's Hospice!
Make an exhilarating 10,000ft tandem skydive for Acorns Children's Hospice! Sunday 30 th September 2012 Hinton Airfield, Brackley Northamptonshire The Acorns tandem 10,000ft freefall skydive! Imagine sitting
More informationPARTICULARS OF POLICYHOLDER / INSURED PERSON / CLAIMANT (to be completed for all claims) NRIC/Passport No.
Travel Claim Form The acceptance of this Form is NOT an admission of liability on the part of HL Assurance Pte. Ltd.. Any documentary proof or report required by HL Assurance Pte. Ltd. shall be furnished
More informationTravel Claim Form Medical Expenses/ Curtailment and Repatriation
Travel Claim Form Medical Expenses/ Curtailment and Repatriation 1 GUIDANCE NOTES MEDICAL EXPENSES, CURTAILMENT AND REPATRIATION Most delays in settling claims arise because claim forms are not fully completed
More informationCHECKLIST OF DOCUMENTS REQUIRED. DOCUMENTATION SHOWING YOUR TRAVEL DATES AND FULL COST OF THE TRIP (booking invoice)
PA PERSONAL ACCIDENT Dear Customer, Travel Claims Facilities PO Box 395 Monks Green Farm Mangrove Lane Hertford SG13 9JW Email: claims@tif-plc.co.uk Web: www.tifgroup.co.uk In order that we can process
More informationSUREFIRE BUSHCRAFT
BUSH CRAFT AND SURVIVAL COURSE INDIVIDUAL DETAILS AND CONSENT TO PARTICIPATION Name inc. Title Course Date Course Fee Home Address Course Title Date of Birth: N.H.S. number Blood Group Have you received
More informationFundraising Agreement between Macmillan Cancer Support and Event Participant
Fundraising Agreement between Macmillan Cancer Support and Event Participant Thank you for committing to raise money for Macmillan Cancer Support through your participation in the Borneo Hiking Challenge,
More informationPRIME INSURANCE COMPANY LIMITED Head Office: 63, Dilkusha C/A (6 th Floor), Dhaka-1000.
PRIME INSURANCE COMPANY LIMITED Head Office: 63, Dilkusha C/A (6 th Floor), Dhaka-1000. PROPOSAL FORM FOR OVERSEAS MEDICLAIM POLICY (CORPORATE FREQUENT TRAVEL) (To be submitted in original with two copies)
More informationSelf Employed Disability (Accident or Sickness) Claim Form
Self Employed Disability (Accident or Sickness) Claim Form Section A Your details (To be completed by your) Title Surname Forename(s) Address Home Telephone Number Alternative Telephone Number Email Address
More informationSt David s Hospice Hosbis Dewi Sant
St David s Hospice Hosbis Dewi Sant Abbey Road/Ffordd yr Abaty, Llandudno, Conwy LL30 2EN Tel/Ffôn: 01492 879058 Fax/Ffacs: 01492 872081 www.stdavidshospice.org.uk enquiries@stdavidshospice.org.uk Cwmni
More informationRegistration Form Pilgrimage 2017
Registration Form Pilgrimage 2017 In the Footsteps of St Columban August 13, 2017 - September 3, 2017 DUBLIN LUXEUIL BREGENZ DISENTIS OLIVONE BOBBIO MILAN ROME (IRELAND) (FRANCE) (AUSTRIA) (SWITZERLAND)
More informationPrairies to Peaks Iron Horse Rail Summer Camp REGISTRATION AND HEALTH FORM
Prairies to Peaks Iron Horse Rail Summer Camp REGISTRATION AND HEALTH FORM Section 1 Basic Contact Information Campers Name: _ Nickname:_ Birth date / / Gender: Male Female T-shirt size: Adult / Youth
More informationTravel Insurance Claim Form
What You Need To Do Before making a claim, it is important to have the following information available: 1. Your travel insurance policy number (from your Certificate of Insurance) 2. Your daytime contact
More informationSelf Employed Disability (Accident or Sickness) Claim Form
Self Employed Disability (Accident or Sickness) Claim Form Section A Your details (To be completed by your) Title Surname Forename(s) Address Home Telephone Number Alternative Telephone Number Email Address
More information2015 YOUTH SUMMIT: TOGETHER WE CAN
2015 YOUTH SUMMIT: TOGETHER WE CAN What is Project UNIFY? Project UNIFY is a sports and education program that partners students with and without intellectual disabilities to create a more inclusive school
More informationTRIP REGISTRATION FORM 25% PER PERSON INITIAL DEPOSIT* DUE UPON BOOKING *35% PER PERSON INITIAL DEPOSIT FOR CRUISES AND THE GALAPAGOS
976 Tee Court, Incline Village, NV 89451 Tel: (800) 670-6984 or (775) 832-5454 Fax: (775) 832-4454 www.mythsandmountains.com travel@mythsandmountains.com TRIP REGISTRATION FORM 25% PER PERSON INITIAL DEPOSIT*
More informationAPPLICATION TO REGISTER A DEPENDANT
APPLICATION TO REGISTER A DEPENDANT SECTION 1 TO BE COMPLETED BY MEMBER Principal member s name: Principal member s address: Postal code: Cell number: Medical aid number: Payroll/persal number: SECTION
More informationThe New India Assurance Company Limited
The New India Assurance Company Limited Regd. & Head Office: New India Assurance Building, 87, M.G. Road, Fort, Mumbai -400001 years) PROPOSAL FORM FOR OVERSEAS MEDICLAIM POLICY (Business & Holiday) (To
More information15,000FT TANDEM SKYDIVE FOR NORTH DEVON CHEMO APPEAL
TANDEM SKYDIVING 15,000FT TANDEM SKYDIVE FOR NORTH DEVON CHEMO APPEAL Combine the most exciting moment of your life with raising money for North Devon Chemo Appeal Situated at Dunkeswell, near Honiton,
More informationSouth Pacific Division Club
NAD International Camporee, 2009 South Pacific Division Club Newsletter 1 / May 2008 Page 1 Dear Pathfinders/Staff, As many of you may be aware, the North American Division (NAD) International Camporee,
More informationTravel Claim Form Cancellation
Travel Claim Form Cancellation 1 GUIDANCE NOTES CANCELLATION Most delays in settling claims arise because claim forms are not fully completed or requested documents are not sent to us. We would therefore
More informationLearning Without Limits
Learning Without Limits Address: West Haddon Rd Guilsborough, Northampton, NN6 8QE T: 01604740641 F: 01604 749104 Principal: Mrs J S Swales BSc (Hons) Activity: Sports Tour Venue/Destination: Barcelona,
More informationAMBASSADOR APPLICATION AND AGREEMENT
Page 1! of 5! AMBASSADOR APPLICATION AND AGREEMENT A Friendship Force Exchange offers an opportunity for people from different parts of the world to share their lives with each other in the spirit of friendship.
More informationGROUP TOTAL & PERMANENT DISABILITY CLAIM FORM
Dear insured employee, GROUP TOTAL & PERMANENT DISABILITY CLAIM FORM We are sorry to learn about your illness/accident. In order for us to process your claim, we require the following: (1) Group Total
More informationCLAIM FORM FOR MEDICAL EXPENSES AND OTHER EXPENSES
CLAIM FORM FOR MEDICAL EXPENSES AND OTHER EXPENSES Please note that we have to ensure that our claim form covers all types of claim. If you do not consider a question to be relevant to your circumstances
More informationKing Charles I School
King Charles I School Supporting successful futures Headteacher: Stephen Brownlow Dear Parents/Carers, Year 10 Trip to Berlin (Germany) in October 2017 November 2016 Following successful overseas trips
More informationMexico Japan Exchange Program for the Strategic Global Partnership APPLICATION FORM
APPLICATION FORM Please type in capital letters. Do not leave any space blank. Use N/A when applicable. 1. Title of the Training Program: 2. Applicants particulars AFFIX A RECENT PASSPORT-SIZE PHOTOGRAPH
More informationChiropractic Case History / Patient Information
Chiropractic Case History / Patient Information Date: Name: Social Security #: Home Phone:( ) Address: City: State: Zip: E mail address: Cell Phone:( ) Age: Birth Date: / / Marital Status: M S W D Occupation:
More informationMAG Tours & Safaris accepts bookings subject to the following Terms and Conditions
MAG Tours & Safaris accepts bookings subject to the following Terms and Conditions 1. Your contract with MAG Tours & Safaris Deposit: 50% of the total Invoice price. To secure a booking with MAG Tours
More informationWhat is it like? What does the jump involve?
What is it like? Imagine standing at the edge of an open doorway in an aircraft flying at 10,000 ft - the noise of the engines and the wind ringing in your ears with only the outline of distant fields
More informationElite Athlete Strength and Conditioning Camp
Elite Athlete Strength and Conditioning Camp For your child s safety, and in order to be permitted to participate in all activities, please fill out this form and return it to St. Michael s Summer Camps
More informationI am pleased to offer your child a place on the trip to Sorrento during Enrichment Week 2019.
Station Road, Backwell, Bristol BS48 3BX Tel: 01275 463371 mailbox@backwellschool.net www.backwellschool.net Headteacher: Jon Nunes MA May Dear Parents/Carers Enrichment Week Sorrento I am pleased to offer
More informationClaim Form - Travel Insurance
Claim Form - Travel Insurance Important tice: To enable us to process your claim, please submit the duly completed claim form with supporting documents in original as listed in the subsequent section.
More information20 JUNE 2015 TANDEM SKYDIVE GUINNESS WORLD RECORD ATTEMPT
Official World Record Attempt in aid of Pancreatic Cancer Action 24 HOURS 333 PEOPLE 20 JUNE 2015 TANDEM SKYDIVE GUINNESS WORLD RECORD ATTEMPT TH Join us for possibly the biggest ever tandem skydive event
More informationParental Consent Form
Parents and legal guardians of minor children must complete this form and return it to the Convoy of Hope Compassion Teams. The information requested is designed to assist in providing for the safety of
More informationFLEXI HEALTH PLAN INDIVIDUAL AND FAMILY HEALTH INSURANCE PLAN APPLICATION FORM
FLEXI HEALTH PLAN INDIVIDUAL AND FAMILY HEALTH INSURANCE PLAN APPLICATION FORM Please use BLOCK letters to complete this form. Proposal form once accepted, becomes part of the policy document. Member Information
More information2010 FMSCI Karting Competition License Application Form
Instructions 2010 FMSCI Karting Competition License Application Form 1) Please write in CAPITAL letters ONLY 2) Please attach 2 Stamp Size Photos for each license applied for. 3) If you are 18 years and
More informationOverseas study protection plan claim
Overseas study protection plan claim Important notice If we accept this form, it does not mean we are taking legal responsibility for your claim. If we ask for any documents as proof or a report, you will
More informationEKU Educational Talent Search Program Student Leadership Team
EKU Educational Talent Search Program Student Leadership Team 2018-19 Dear ETS Participant, You have indicated an interest in being on the ETS Student Leadership Team. It will be necessary for us to meet
More informationAFRICA NEEDS LIONS Sponsored Parachuting
AFRICA NEEDS LIONS Sponsored Parachuting ALERT (UK) 39 St. James s Place London SW1A 1NS United Kingdom T: + 44 (0)20 3371 7835 e: info@lionalert.org w: www.lionalert.org Thank you for your enquiry about
More informationWorker s Compensation Intake Form
Worker s Compensation Intake Form Patient Information Date of Birth: / / Social Security: - - Address: Street City State Zip Email Address: Home Phone: Cell Phone: Gender: Height: Weight: lbs Marital Status:
More informationArizona Center for Aesthetic Plastic Surgery Steven H. Turkeltaub, M.D., P.C. Certified, American Board of Plastic Surgery
Referred By: Patient Last Name First M.I. Sex Marital of Birth Age Status Present Mailing Address - Street City State Zip Social Security # Home Telephone # Cell phone # Business Telephone # E-mail address
More informationGuidance Notes For Medical Expenses Claims
Guidance Notes For Medical Expenses Claims Please submit originals of the following (photocopies are not acceptable, but we would suggest that you may wish to keep a copy for your own records): The Insurance
More informationCombined Insurance Claim Form
Combined Insurance Claim Form Important Instructions on How to Complete the Attached Claim Form and How We Assess Claims Please read these important instructions on how to complete the attached Claim Form.
More informationHaematology Department. Sir Geoff Hurst MBE : Fax:
Patrons: Haematology Department Rt Hon the Countess Bathurst Cheltenham General Hospital Laurence Llewelyn-Bowen Sandford Road Jackie Llewelyn-Bowen Cheltenham Dr P J Crook MBE GL53 7AN Sir Geoff Hurst
More informationEverything you need is enclosed in this pack, making it as easy as possible for you to take part.
Dear Supporter, Do you want to enjoy the exhilarating and unforgettable feeling of a skydive, flying through the clouds from over 10,000 ft at up to 120mph? We are looking for thrill-seeking fundraisers
More informationIDSALL SCHOOL. Headteacher: Mr. P. Bourton
IDSALL SCHOOL Coppice Green Lane, Shifnal, Shropshire TF11 8PD. Telephone: 01952 468400 Facsimile: 01952 463052 Email: info@idsall.shropshire.sch.uk Website: idsallschool.org Private Limited Company No.
More informationMountain Venture Guiding (MGV) -- MVGuides.com 2460 State Route 48, Fulton, NY (315) YOUR ACKNOWLEDGMENT OF THE RISKS
Mountain Venture Guiding (MGV) -- MVGuides.com 2460 State Route 48, Fulton, NY 13069-4139 (315) 529-0283 Before you arrive at your outdoor event, YOU MUST thoroughly read all program materials and call
More information