Queen's Guide Retreat Registration Form

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* 1. Contact Details

Full Name

Address

Address 2

City/Town

Postal Code

Email Address

Phone Number

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* 2. Guardians Contact Details

Full Name

Address

Address 2

City/Town

Postal Code

Email Address

Phone Number

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* 3. What is your date of birth?

DD/MM/YYYY

Date

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* 4. Year at School

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* 5. Area

Upper North (A)

Central Area (B)

Lower North (C)

South Area (D)

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* 6. Hub

Hub 1 - Te Tai Tokerau

Hub 2 - Tamaki Makaurau

Hub 3 - Tamaki ki te Tonga

Hub 4 - Te Puku o te Ika

Hub 5 - Te Tai Rawhiti

Hub 6 - Te Tai Hauauru

Hub 7 - Te Whanganui a Tara

Hub 8 - Te Waipounamu

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* 7. Unit Name

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* 8. ID Number

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* 9. Which retreat do you wish to apply for:

Wellington - 12-14 April 2019

Auckland - 28-30 June 2019

Rotorua - 19-21 July 2019

Christchurch - 11-13 October 2019

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* 10. Please put your second choice

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* 11. My Ranger Leader is aware of my application to attend the retreat

Yes

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* 12. What is your leaders name?

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* 13. Date you completed your Peak Award

Date / Time

Date

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* 14. Dietary Requirements

Terms and Conditions

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* 15. I give you permission to contact my leader to ascertain my suitability for this event.

Yes

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* 16. My emergency contact and personal details on OGM are up to date

Yes

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* 17. I understand this trip needs to run at full capacity for fixed costs to be covered. Therefore should I withdraw after acceptance, a refund will only be given if a replacement is found. If I withdraw because of medical reasons a partial refund may be available on presentation of a medical certificate.

Yes

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* 18. I understand payment must be made at least 21 days prior to the retreat

Yes

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* 19. I acknowledge that I am responsible for all travel costs and that I am not to book travel until I have received the acceptance letter, which will advise suitable arrival/departure times.

I will travel by Air, which I will arrange myself

Other public transport (bus/train) which I will arrange myself

Private car on my own or with others, which I will arrange myself

I am not sure at this time

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* 1. Contact Details

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* 2. Guardians Contact Details

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* 3. What is your date of birth?

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* 4. Year at School

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* 5. Area

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* 6. Hub

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* 7. Unit Name

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* 8. ID Number

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* 9. Which retreat do you wish to apply for:

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* 10. Please put your second choice

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* 11. My Ranger Leader is aware of my application to attend the retreat

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* 12. What is your leaders name?

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* 13. Date you completed your Peak Award

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* 14. Dietary Requirements

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* 15. I give you permission to contact my leader to ascertain my suitability for this event.

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* 16. My emergency contact and personal details on OGM are up to date

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* 18. I understand payment must be made at least 21 days prior to the retreat

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* 19. I acknowledge that I am responsible for all travel costs and that I am not to book travel until I have received the acceptance letter, which will advise suitable arrival/departure times.

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* 20. Is there any other information we should know which may assist with your application?