Hertfordshire Scouts Mountaineering Section Application Form

Basic Information

Trainee’s Name: (BLOCK CAPITALS) / Date of Birth:
Home Address: / M/F
Post Code:
Tel Number: / Home: / Mobile:
Email:
Group and Troop/ Unit:
Scout Membership No and DBS number / Must have If over 18
Course Title: / AMC 2017 Lochearnhead Scout Station
Date: / Wednesday 27th December 2017 – Tuesday 2nd January 2018
Parent/Guardian (if trainee is under 18) or Applicant Sign Off
I hereby give responsibility for me/ my son/daughter to the course Instructors/Leaders/First Aiders, and authorise them to sign on my behalf any papers needed by the medical authorities in case of emergency hospital treatment if the delay to obtain a signature is considered inadvisable by the medical practitioner concerned. This includes authority to act in "Loco Parentis" particularly in regard to my son’s/daughter’s participation in "Adventurous Activities".
I give permission for images of me/my son/daughter to be used for promotional purposes within Scouting.
Signature:
Name:(BLOCK CAPITALS)
Leader Sign Off
I confirm that the applicant is a member of the Scout movement and I recommend the application (not applicable to Network or Leader applicants).
Signature:
Name:(BLOCK CAPITALS)
Position:
Email:

Trainee Next of Kin Information

Next of Kin Name:
(BLOCK CAPITALS)
Relationship:
Contact Address during the course:
Email:
Contact Tel Number: / Home: / Mobile:
Trainee's Medical History
NHS Number
Allergies:
Conditions:
Medication:
Other relevant information: / Please detail overleaf
Special Dietary Requirements
(e.g. Vegetarian)
Tetanus: / Immunised in last 10 yr: Yes / No
Doctor’ s Name: / Tel. No:
Address:

£75 deposit (non-refundable) must be enclosed with the application form. The balance of £190 will be payable at a later date.

Please return this form (scan & email or post) and make a Bank Transfer to: Barclays Bank, Sort Code 20-20-37, A/C # 10798444 with the trainee surname as the reference

Alternatively, send a cheque for £75 payable to Hertfordshire Scouts -Mountain to:

Andrew Rice, 83 Homestead Road, Hatfield, Herts. AL10 0QR

Any Queries please Tel: 07966 671481 or Email: