Livingstone 4X4 Challenge Registration Form
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1 Livingstone 4X4 Challenge Registration Form About You Give forename and surname as they appear on your passport please Title: Surname: Forename: Known As: Home Phone: Work Phone: Mobile Phone: Post Code: Please tick the box if you are happy for us to you with details of forthcoming events and activities we think you might be interested in: Occupation: Department: Employer: Business: T-Shirt Size (Please Circle): S M L XL Emergency Contact Name: Relationship: Home Phone: Work Phone: Mobile Phone: Postcode: More Information Do you have a clean UK driver s license that will be in date during the trip? If taking part with friends, please provide their names Please provide your travel Insurance policy No. Where did you hear about this trip? Please give details of special dietary requirements Passport Information To travel you must have a valid 10 year passport that runs for at least 6 months after your return to the UK. If it doesn t you will need to apply for a new passport as soon as possible. Please forward details to The Nasio Trust as you receive these. I have a valid passport: Yes/No Date of birth: Will you be under 18 on the first day of the trip? Yes/No Participants under 18 must be accompanied by a responsible adult. Passport number: Date of expiry: Date of issue: Nationality: Get to know your travel companions It is our policy to share your contact details with the other participants in your group so you can keep in touch before and after the challenge. If you would not like to be included in this list, please indicate below. Exclude me from the contact list:
2 4X4 Challenge Medical Questionnaire What Is This Information For? The information in this form will be supplied to the Nasio representative on the trip so they are fully aware of any medical conditions you may have. These forms have proved invaluable in the past. The details of your medical history are strictly confidential and the forms will be destroyed after the event. The event you are participating in is challenging and you will need a good level of fitness; it is your responsibility to ensure you have the appropriate level of fitness. There will be personnel with first aid supplies with the group at all times, but often parts of the route will be away from main cities and hospitals (at which medical facilities may be inferior to those in the UK). Before you travel please make sure you visit a travel clinic or your doctor to make arrangements for any vaccinations or medications you may need in order to travel to Kenya. We ask for your kind co-operation in this matter and invite you to phone us on should you have any queries. Are You Aware Of A Pre-Existing Medical Condition? If you have a pre-existing medical condition you MUST ask your doctor to sign this form confirming you are fit to undertake this challenge. Your Doctor s Details Doctor s name: Surgery Tel. Number: NHS Number: Post Code: Your Doctor s Signature If Needed Remember, if you have a pre-existing medical condition, it is compulsory to get your doctor s signature to indicate you are fit to undertake the challenge. I consider the person named in this form to be fit to participate in the 4x4 challenge: Signed: Name: Dr. Date: / /
3 4X4 Challenge Medical Questionnaire Your General Health Please state whether you have or have not got any of the following conditions, If you answer yes to any of these questions please provide further information regarding severity & treatment currently being undertaken. Condition Details Raised blood pressure Heart or circulatory disease Epilepsy and / or fainting attacks Psychiatric or mental illness Chest or lung disease Vertigo Diabetes Joint or back injuries / problems Allergies (Hay fever, dietary, chemicals, drugs etc) Asthma, bronchitis and / or other shortness of breath? Digestive or bowel disorders? Cerebral disease? (e.g. stroke, head injuries etc) Fracture, tendon, ligament / cartilage damage Surgical operations (last 5 years) Haematological or blood disorders Metabolic or endocrinal disorders Are you pregnant? Physical or other disability Carrier of infectious diseases Migraine Hospitalised in the last two years Any illness or conditions not already mentioned
4 4X4 Challenge - Terms & Conditions of Entry 1. All travel and associated arrangements for The Nasio Trust 4X4 Challenge are made by a specialist travel company. In making these arrangements, The Nasio Trust is acting as your agent and is unable to accept liability for any loss or damage, beyond its statutory liability, or for cancellation of the event for any reason out of its control. 2. Participants must raise a minimum of 2,950. The 295 registration fee is non-refundable and forms as part of this amount. We insist that 80% of the total must be paid to The Nasio Trust at least 6 weeks prior to departure. If you do not pay this amount you will forfeit your eligibility to participate or you may choose to make up the balance yourself. We ask that you show pledges for the minimum sponsorship level before departure. The balance of the sponsorship must be paid within four weeks of the end of the trip. Gift aid is a refund that The Nasio Trust can reclaim from HMRC on certain donations. Any gift aid reclaimed does not contribute towards your fund raising target. 3. Registration fees are non-refundable under any circumstances once you have been accepted on the event. 4. If participants decide at any time not to take up their places, all sponsor forms and sponsor monies collected and held by the participant must be forwarded to The Nasio Trust, so they can be returned to the sponsor if requested. 5. If, for what ever reason, you withdraw from the event after the 6 weeks before departure deadline, you are personally liable for any cancellation charges payable in accordance with the terms and conditions of Travel Company. This will be the prescribed percentage of the trip cost. 6. Participants wishing to withdraw from the event after registration must confirm their cancellation in writing to The Nasio Trust. Without this, The Nasio Trust is unable to accept their cancellation. 7. Gift Aid does not count towards participants sponsorship target. 8. The trip costs include all group international flights and internal transfers thereafter, project equipment, accommodation on a twin share basis or as dictated by local conditions (e.g. hostel, hotel or camping), most meals, guides, group camping equipment, some sightseeing trips or site/park entry fees. 9. The following are not included in the cost of the trips: items of a personal nature (e.g. telephone calls, laundry, tips etc), drinks, certain meals, visas, vaccinations, insurance and local airport and/or departure taxes. 10. You must take out travel insurance covering health, accident and loss, emergency repatriation etc. while you are out of the UK. Travel Company can provide a suitable policy or, if you have your own insurance, The Nasio Trust must be given a copy to ensure it is suitable for the event. 11. You must hold a 10 year passport that is valid for six months after your return to the UK. It is your responsibility to obtain a valid visa (if required), the cost of which is not included in the cost of the trip. The information supplied regarding passports and visa requirements was correct to the best of our knowledge at the time of printing. You must check current requirements with the Foreign and Commonwealth Office ( who will provide information on health and security. 12. All instructions given to you on the event must be observed for your own safety. Participation in this event is at your own risk. 13. Participants must carry out all fundraising in accordance with the guidelines set out in The Nasio Trust fundraising pack and Professional Fundraiser s Agreement. This will be sent upon confirmation of your place on the event and must be returned immediately to The Nasio Trust after participants have read, signed and dated the form. 14. Your place on the event is not secured until The Nasio Trust is in receipt of the signed and completed registration forms & deposit and medical form upon which you agree to the terms and conditions issued by Travel Company. 15. The registration fee and all sponsorship is payable to The Nasio Trust. 16. The Nasio Trust reserves the right to amend or change the itinerary without prior notice. 17. The Nasio Trust reserves the right to not accept a participant onto a challenge at any point leading up to departure of the trip. 18. Participants will normally only be accepted on a Nasio Trust overseas challenge if they are at least 18 years of age by the first day of the trip. Any Participants that are under 18 years of age on the first day of the trip will only be accepted if they are accompanied by a parent / guardian or other adult who are responsible for them. Any Participants under 18 on the first day of the trip must provide a parent / legal guardian consent form agreed with the responsible adult. I hereby agree to abide by the terms and conditions of the entry as detailed above and by signing this form I acknowledge that I have read, understood and accepted the conditions of contract set out by The Nasio Trust. Your Signature Signature Of Parent/Guardian* Signed: Signed: Date: / / Name: Date: / / Details Of Accompanying Responsible Adult (If Applicable) *Required if registrant is going to be under 18 on first day of travel Signed: Name: Date: / / What is your relationship to the registrant?
5 4X4 Challenge Registration Fee About Your Registration Fee A registration fee of is required to join the event and is non-refundable once you have been accepted on the event. Please make the cheque payable to The Nasio Trust. Stay Up To Date With The Nasio Trust The Nasio Trust would like to keep you up to date with the work of the charity including fund raising activities using the contact details you have provided, which we hope will be of interest to you. If at any time you do not wish to receive this information please contact us at the address provided or tick this box: Returning Your Form Please return your completed form and registration fee to: The Nasio Trust, Hampden House, Monument Park, Warpsgrove Lane, Chalgrove, Oxford, OX14 1RL
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Student No: Application form Solely for applications not handled by the Universities and Colleges Admissions Service (UCAS) or UCAS Teacher Training (UTT). Please read the accompanying Notes for Guidance
OSG Travel Claims, PO Box 1086, Belfast, BT1 9ES Email : info@osgtravelclaims.co.uk Tel: 020 7581 6444 Medical - Claim Form
OSG Travel Claims, PO Box 1086, Belfast, BT1 9ES Email : info@osgtravelclaims.co.uk Tel: 020 7581 6444 Medical - Claim Form CLAIM No:- For Office Use Only OSG Travel Claims are committed to providing a
Patient History Information
Date: Body Technic Systems, Inc. 33790 Bainbridge Rd. Ste. 205 Solon, Ohio 44139 440-248-9255 phone 440-248-3608 fax Patient History Information Name: Date of birth: Address: City: State: Zip: Home phone:
Rahab s Rope Application Instructions:
We are so excited to have you join our work in India. The first step in the process for any volunteer is to fill out the following application in full. Rahab s Rope Application Instructions: Complete the
Medicare Patient Information. Patient Name: SS#: - - Date of Birth: / / Sex: Female Male. City: State: Zip Code:
Medicare Patient Information Patient Name: SS#: - - Date of Birth: / / Sex: Female Male Address: Street: City: State: Zip Code: Home Phone: ( ) - Work/Mobile Phone: ( ) - Please print your name as it Appears
How To Fill Out A Health Declaration
The English translation has no legal force and is provided to the customer for convenience only. The Dutch health declaration should be filled in. Health declaration for occupational disability insurance
We are writing further to your request for a claim form and are very sorry to note the circumstances described.
PO Box 5775 Southend-on-Sea Essex SS1 2JY Dear Sir/Madam Travel Insurance Claim We are writing further to your request for a claim form and are very sorry to note the circumstances described. In order
PATIENT REGISTRATION FORM PATIENT INFORMATION
Siepser Laser Eye Care PATIENT REGISTRATION FORM : PATIENT INFORMATION First Name Middle Initial: Last Name: Birth : Gender: Male Female Marital Status: SSN: Driver s License #: Address: City: State: Zip:
Incoming Medical Elective Application Form
Incoming Medical Elective Application Form Fully completed applications must be submitted at least 6 months in advance of the elective Section 1: Student Details Surname: Mr/Mrs/Miss Forename(s): Date
Police Certificate Instructions. It is essential that Project Trust volunteers obtain a Police Certificate prior to going overseas.
Police Certificate Instructions It is essential that Project Trust volunteers obtain a Police Certificate prior to going overseas. This can be a lengthy process so please ensure that you apply online immediately.
460 Main St, East. Unit M3 Hamilton, ON L8N 1K4 T: 905 524 3709 F: 905 524 4866 info@physiotherapyclinic.ca
Page 1 of 6 Date Patient Information (Please complete all fields below) Last Name First Name Intl. Street Address Home Tel. City/Town Province Postal Code Work Tel. Date of Birth (mm/dd/yyyy) Gender M
Travel Claims Form STEP 1 CLAIM FORM COMPLETION REQUIREMENTS STEP 2 CLAIMANT DETAILS. Policy and Claimant Details. A. Travel Arrangements
STEP 1 CLAIM FORM COMPLETION REQUIREMENTS Please read and complete this form. Please retain a copy of ALL documents for your records. Documents in a foreign language are required to be translated into
We are writing further to your request for a claim form and are very sorry to note the circumstances described.
PO Box 5775 Southend-on-Sea Essex SS1 2JY Dear Sir/Madam Travel Insurance Claim We are writing further to your request for a claim form and are very sorry to note the circumstances described. In order
Claim Number. Departure Date: From / / To / / Occupation Date of Birth / / Date of Booking Travel Arrangements Date of Departure Date of Return
Savannah Insurance Agency Pty Ltd ABN 84 130 364 313 Corporate Travel Claim Form Details of the Insured Insured Name (Traveller) Policy Number Claim Number IMPORTANT 1. Please complete the Policy Details