Registration Forms. Salkantay Inca Trail Challenge COMPLETE YOUR CHALLENGE OF A LIFETIME AND HELP OTHERS TO FACE THEIR PERSONAL CHALLENGES

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