2019 Programme Enrollment
Hillary Outdoors Education Centre - Great Barrier Island (Aotea)
PARTICIPANT DETAILS
First Name *
Your answer
Surname *
Your answer
Which programme are you enrolling in?
Gender *
Age *
Your answer
School *
Your answer
Contact email; further information including travel documents will be sent to this address *
Your answer
Please tick the box if you do NOT want to receive information about other courses at Hillary Outdoors. At no time will we ever sell or provide your information to anyone else.
NEXT OF KIN / EMERGENCY CONTACT
Name *
Your answer
Relationship to participant *
Your answer
Phone 1 *
Your answer
Phone 2
Your answer
PERSONAL INFORMATION
Hillary Outdoors has a policy of inclusion. In order to achieve this safely it is vital that we have as much information as possible about our participants. It is ESSENTIAL that you give us accurate and detailed information. Note: Any information provided will be treated as confidential.

IF ANYTHING CHANGES BETWEEN COMPLETING THIS FORM AND THE TRIP IT IS ESSENTIAL YOU LET US KNOW.

Do you have any particular dietary needs? *
If you do have particular dietary needs please give details
Your answer
Do you have any medical conditions? E.g. injuries, allergies, anxiety, diabetes, obesity, behavioral, addiction, sight or hearing impediments or other. *
If you do have a medical condition/s please give details
Your answer
Are you taking any medication? *
If you are taking medication please give details. (Please bring spares of any medication for your instructor to carry)
Your answer
I agree to me/my child being given over the counter medication e.g. Panadol or ibuprofen *
SWIMMING ABILITY INFORMATION
Are you able to swim 50 metres *
Are you confident in the ocean? This includes surf, open and deep water. *
CONSENT
Detailed information about our safety system and activities is provided at www.hillaryoutdoors.co.nz/safety/

IN SUMMARY:
- Hillary Outdoors offers a wide range of activities which may include: sea kayaking, sailing, coasteering, snorkeling, rock-climbing, tramping, ropes courses, abseiling and surf kayaking
-Participation in all activities a Hillary Outdoors is voluntary although student are supported and encouraged by their peers and instructor to participate to a level which challenges them.
-Because of the changeable and unpredictable nature of the outdoors risks can never be reduced to zero. Hazards exist in these activities that may result in serious injury or even death. These hazards include: weather / environmental conditions, height, water, equipment, Hillary Outdoors employees' behaviour and skills, client specific hazards, environmental impact and vehicles.
- Our aspirational goal is that no harm will occur whilst involved in activities. Our management strategies for achieving this can be viewed online.

PLEASE CONTACT US IF YOU REQUIRE MORE INFORMATION TO MAKE A DECISION, OR IF YOU HAVE ANY QUESTIONS

Please read each statement and then indicated your consent below.
- I understand there are risks associated with outdoor activities that cannot be reduced to zero. I know I am able to ask any questions of Hillary Outdoors or the individual instructor to gain a better understanding of the activity before deciding whether to take part, and the final decision about whether to take part or not is mine. If I decide to take part, I understand the instructor will identify any hazards that are liable to arise and correct procedures to deal with these, and that it is necessary for me to follow these. The instructor will take all reasonable precautions to ensure my safety. If I act outside of this advice, then I acknowledge I do so at my own risk and may be instructed to leave the programme or activity.

- I have received enough information to make an informed decision about the programme I am / my child is about to undertake.

- I authorise Hillary Outdoors to instigate medical assistance and treatment required in an emergency.

- I understand I may be charged for items belonging to Hillary Outdoors I lose or damage.

- I understand that my personal effects are not covered by Hillary Outdoors insurance policy.

- I understand that if I am under the influence of alcohol, drugs or other substances, Hillary Outdoors has the right to stop my further participation on the programme and I have no right for refund of my course fee.

- I have read the information sent to me and agree to act within Hillary Outdoors' policies and expectations. I understand that Hillary outdoors cannot be responsible for storage or administration of my child’s medication, unless specifically requested to do so prior to their visit.

PLEASE CONTACT US IF YOU REQUIRE MORE INFORMATION TO MAKE A DECISION, OR IF YOU HAVE ANY QUESTIONS

I the participant AND the parent/guardian agree with ALL of the above. *
We require all participants to complete this form and parent/guardians to confirm their permission for their child to participate if they are under the age of 18. Photos and videos of participants to our courses and programmes may occasionally be used for marketing purposes. We assume your permission to any of you / your child unless otherwise requested by you.

By completing your name and the date below you are confirming that the information provided is as accurate and as complete as possible and you are confirming that your /your child's participation is in the stated Hillary Outdoors programme.

Parent / Guardian's Name
Your answer
Date
MM
/
DD
/
YYYY
Participant's Name
Your answer
Date
MM
/
DD
/
YYYY
Thank you
We will be in touch shortly to confirm your spot and provide further information
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