Activitesperiscolaires.lu

Application form
Please complete this form using CAPITAL LETTERS and black ink only. Please write only within the boxes and hand in to your organising teacher when complete. Expedition details
School / College
Challenger details
First name
We will be passing on your address details to carefully selected partners to provide discounts
on clothing, vaccinations etc. If you would like us NOT to pass on your details, please tick this box
Please cross this box if the Challenger has any dietary Challenger passport details
Main guardian/parent details
Title
If the main guardian lives at a different address to the applicant then please fill in this section. Otherwise please leave blank.
World Challenge is part of the TUI Travel PLC Group of Companies. Please cross here if the main guardian does NOT wish to receivethe latest news and family offers from other TUI companies. We will not pass your information onto any third parties outside of TUI.
Second guardian/ parent details
Title
Medical information
Please complete either section A or B
SECTION A - please tick if you have ever suffered from the following
We need to know of any other medication thatChallengers will be taking whilst on expedition.
Allergies (other
Back trouble
Depression
Please mark if you take any of the following: than hayfever)
Diabetes
Eating disorder
Epilepsy
Acne medication
Contraceptive pill
condition
Joint problems
Migraines
Psychiatric
Eczema Medication
Hay fever medication
Please mark if you agree with any of the following statements: The Challenger has objections to blood transfusions
The Challenger has objections to medical treatment
whilst on expedition or in preparation e.g. immunisation
The Challenger has other conditions or takes
other medication that is not covered by the above
In order to ensure the safety of the Challenger and to validate their insurance during the expedition, we will pass the information you provide in this section to our insurers, medical advisers and your
Expedition Leaders. Please sign below to agree to these details being used in this way. We cannot process this application without such authorisation. We will not use the information you provide other than
the reasons set out above and shall not forward the information to any third parties without first obtaining your consent.
SECTION B
I currently have no medical conditions or objections
Should your situation change at any time regarding medical conditions or to declare
medication taken, please inform us as soon as possible. We can thereforeprovide the safest expedition possible and ensure you are medically insured.
Declaration of Challenger and parental / legal guardian consent
If the Challenger will be under the age of 16 at the time of departure:
We wish to ensure that, in the event of an emergency, we have all the necessary permissions to enable the Challenger to receive appropriate medical care as soon as possible. It is therefore necessary for us to have signed authority to enable the Expedition Leader, Expedition Assistant (if present), or School Leader, nominated by World Challenge, to sign on your behalf before any medical treatment, such as general anaesthetic, may be given to the Challenger (please see points 4 & 5 below).
If the Challenger will be under the age of 18 at the time of departure:
The consent of the parent and legal guardian is required for Challengers to partake in some activities during their expedition, such as white water rafting or swimming. All activities will take place with a provider that has been approved by the World Challenge Operations Director and in accordance with the World Challenge risk assessments. In addition to this, safety will also be assessed on the ground by the Expedition Leader who will ensure that the necessary safety equipment is provided before taking part in any activity (please see points 6 & 7 below).
I agree to the Challenger taking part in the expedition agreed by the School and I agree to the Challenger receiving medication as instructed (unless specified above) and any emergency dental, medical or surgical treatment whilst on the expedition, including, but not limited to: Diamox (for high altitude expeditions), anaesthetic and/or blood transfusion as By signing this application form you agree that you have read and accepted our considered necessary by the medical authorities present.
terms and conditions which will apply to your booking, which can be found at www.world-challenge.co.uk/tandc
I agree to the Challenger taking part in the activities detailed in the expedition specific itinerary, which will be available at least four months before departure, and understand that I confirm that, to the best of my knowledge, this Challenger application form has been I have the opportunity to withdraw consent once the specific activities have been confirmed completed accurately, and I agree to inform World Challenge immediately in writing of any nearer the time of expedition. I understand that this withdrawal of consent must be made changes to the information contained in this form.
I authorise the Expedition Leader, Expedition Assistant (if present) and School Leader, I confirm that the Challenger is able to swim 50 metres unaided.
nominated by World Challenge, to sign any consent forms required by the medical authorities present before any medical treatment, such as general anaesthetic, may be given Signed and endorsed by legal guardian
Signed by Challenger
World Challenge 17 - 21 Queens Road, High Wycombe, Buckinghamshire, HP13 6AQ, UK T +44 (0)1494 427600 F +44 (0)1494 444996 E [email protected]
www.world-challenge.co.uk
World Challenge Expeditions Limited, registered number 2173751, a wholly owned subsidiary of TUI Travel PLC. Registered office address at:
TUI Travel House, Crawley Business Quarter, Fleming Way, Crawley, West Sussex, RH10 9QL, UK
Licensed by Commission for Aviation Regulation

Source: http://www.activitesperiscolaires.lu/files/2012_Application_form_BLANK.pdf