Ahi Kaa Application

Wānanga Date is 23 – 27 January 2015

Closing date for receiving applications is 30 November 2014

Conditions

MEDICAL CERTIFICATE

We require you to provide a Medical Certificate from your doctor that declares you physically capable of participation in the programme. This must be attached to the application. You will need a reasonable level of fitness.

ACKNOWLEDGEMENT OF RISK

There is an element of risk with the activities on this programme. This is what makes it an adventure. These risks are managed by the facilitators who make decisions about acceptable risks, whilst enabling students to build their skills, knowledge, experience, confidence and judgment.

Facilitators will make decisions on behalf of the group about the acceptability of certain risks. Participants must follow the instructions of Facilitators / Guides in regards to safety and risk management.

PARTICIPANTS CONSENT

I understand that there are risks associated with activities in the outdoors. I am aware that my facilitators will take all reasonable steps to manage these risks to an acceptable level and to set appropriate safety standards. At any time during the wānanga I understand that I am free to ask information on an activity and make my own decision on the level of involvement suitable for me alone. Where the level of risk has been stated unacceptable by a facilitator, or me, I agree to refrain from taking any actions affecting the safety of myself or others whilst I am taking part in this wānanga.


Personal Details
Participants Full Name: *
Participants Full Name:
Address:
Address:
Telephone 1:
Telephone 1:
Telephone 2:
Telephone 2:
Doctors Name:
Doctors Name:
Doctors Telephone:
Doctors Telephone:
Emergency Contact Details
Name(s):
Name(s):
Address:
Address:
Telephone (Home)
Telephone (Home)
Telephone (Work)
Telephone (Work)
Telephone (Mobile)
Telephone (Mobile)
Do you have any special dietary requirements? E.g. vegetarian
Do you suffer from sea or motion sickness?
Do you smoke?
Are you a confident swimmer? E.g. can you stay afloat in water above your head?
Have you had any experience in the following activities?
Medical Disclosure (tick all those that apply)
Do you have any behavioral issues (ADD, ADHC, Aggression) developmental issues (e.g. aspergers, dyspraxia) or difficulty functioning with others?
Are you on any medication?
Are you or is there any chance you could you be pregnant?
Is there anything else we should know about you?
MEDICAL CONSENT
In case of severe allergic reaction to a wasp/bee sting: *
Choose one
All this information will remain confidential to the Ahi Kaa programme. Please contact the Coordinator with any queries relating to the medical and consent form.
Date
Date