Breakaway Registration - July 2020

To be eligible, you need to be in the zones of the Whau, Henderson-Massey and Waitakere Boards. If you would like to take part in our event, please fill in your details in this Event Registration Form below. From there we will send you confirmation within 5 work days.

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* 1. Participant's First Name

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* 2. Participant's Last Name

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* 3. Email Address

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* 4. Street Address

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* 5. Suburb

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* 6. Postcode

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* 7. Gender

Male

Female

Other

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* 8. Date of Birth

Date / Time

Date

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* 9. Age (at time of programme)

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* 10. Ethnicity

NZ European

Other European

Maori

Pacific Island

Asian

Indian

African

Latin American

Middle Eastern

Other (please specify)

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* 11. Name of Iwi (if applicable)

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* 12. Country of Birth

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* 13. Programme (pick ONE only)

Juniors (Aged 11-13): 13-15 July

Seniors (aged 14-17): 13-15 July

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* 14. Medical Concerns

Yes - Allergies (please specify below)

Yes - Diabetes

Yes - Asthma (please specify below)

Yes - Epilepsy

Yes - Heart Complications (please specify below)

Yes - Poor Balance

Yes - Other

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* 15. Please advise any other medical concerns which could effect your participation in any activities or any other special instructions that your Instructor should know about:

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* 16. Are you confident in water?

Yes

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* 17. Are you able to swim 200m non-stop?

Yes

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* 18. Parent/Caregiver/Guardian First Name

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* 19. Parent/Caregiver/Guardian Last Name

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* 20. Emergency Contact - Name

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* 21. Emergency Contact - Phone

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* 22. Terms and Conditions

While recognising that Adventure Specialties Trust instructors will be doing their best to ensure safety and manage the risks inherent in the activities my child is participating in, I accept responsibility for their actions and safety.

I authorise Adventure Specialties Trust to administer “over-the-counter” medication as required and within the manufacturer’s guidelines. Furthermore, in the event of an accident or illness, I authorise the obtaining of such medical assistance for my child as may be thought necessary by the staff of Adventure Specialties Trust at my expense.

I agree to reimburse the cost of any deliberate or malicious damage caused to gear or property.

I understand that photos may be taken during the programme that my child is included in. I agree that these may be used for later promotion of Adventure Specialties Trust.

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* 23. How did you hear about our Break-Away School Holiday Programmes?

Facebook

Adventure Specialties Trust Website

Other (please specify)