THE SCOUT ASSOCIATION OF AUSTRALIA

NEW SOUTH WALES BRANCH

GREATER WESTERN SYDNEY REGION

WATER ACTIVITY

APPLICATION TO PARTICIPATE

 

INSTRUCTIONS:            Print details on this form, attach payment for the full fee for the Water Activity Course in which you wish to participate and send it directly to SCOUT ASSOCIATION OF AUSTRALIA NSW.  6 Baden Powell Place, Winston Hills, 2153. Make your cheque payable to “The Scout Association of Australia, NSW Your application must be received at Region Headquarters at least 2 weeks prior to the course commencement date.

COURSE DETAILS

Course Name.......................................................Course Date (s)....................................

 

Course Location................................................................................................................

 

Qualifications to be obtained.

Canoeing Level                                                      FLAT WATER                                                                        white water           

                                                                Canadian                                               Kayak                                     Canadian                               Kayak    

LEVEL 1 (INTRODUCTION)                                                                                                                                                                  _

LEVEL 2                                                                                                                                                                                                 

LEVEL 3 (EXPEDITION)                                                                                                                                                                        _

 

 

Please list your partner’s name if you will be paddling C2         (Canadian)

 

PERSONAL DETAILS

 

Membership Number: ……………………………………………..

 

Family Name Mr,/Mrs,/Miss/Ms...........................................................................................

 

Given Name...........................................................................................................................

 

Address.................................................................................................................................

 

            ......................................................................Post Code...........................................

 

Telephone (Home)....................................................(Work)..................................................

 

email ……………………………………………………………………………………………..

 

Date of birth...............................................................Age.....................................................

 

SCOUTING DETAILS

 

Appointment.........................................................Group....................................................................

 

Region...........................................................................

 

PRE-COURSE QUALIFICATIONS:

First Aid Certificate:   Type.......................................................Expiry Date.......................

List Water Qualifications currently held and date they were attained.

..........................................................................................................................................

 

...........................................................................................................................................

 

CONSENT FORM      (to be completed by Parent/Rover/Leader)

 

Name of Participant...............................................................................................................

 

Name of Group......................................................................................................................

 

Address of Participant...........................................................................................................

 

..........................................................................................Post Code....................................

 

Date of Birth..............................................Age....................Can he/she swim.......................

 

Health and fitness Aspects of participant that may require special attention.........................

 

..............................................................................................................................................

 

..............................................................................................................................................

 

Medicare Number................................................other Health Fund......................................

 

In case of Emergency, contact...................................................Phone.................................

 

I consent to...................................................attending the ...................................................

 

activity from....................................................to....................................................................

 

I understand that while every care will be exercised by those in charge of this activity, I agree to and do hereby indemnify the Scout Association of Australia, New South Wales Branch, it’s officers, members, servants, and agents insofar as to the extent to which the said Branch it’s officers, members, servants and agents are not entitled to be indemnified under any policy of insurance, from and against all actions, suits, damages, claims and demands arising out of any accident, injury, illness, which may befall or occur to the said applicant during or as a result of participation in any activity or function connected with the said Branch or the Scout Movement in New South Wales or when travelling to or from such activity or function or arising out of the death of the said applicant during or as a result of participation in any activity of function connected with the said Branch or Scout Movement in New South Wales or when travelling to and from such activity.  I further authorise any officer, member, servant of the said Branch in the event of such accident or illness to obtain such medical assistance or treatment for the said applicant as he or she may consider necessary and for this purpose engage and doctors, nursing assistance or hospital accommodation and in the event I agree to pay the said Branch on demand all such doctors, nurses and hospital fees and expenses (other than fees and expenses recoverable by the said Branch under any policy of insurance).

 

SIGNED.............................................................................DATE......................................................

 

PRE-COURSE ADMINISTRATION   (OFFICE USE ONLY)

 

Application Received.........................................Eligibility Checked...............................................

 

Course fee received $........................................Receipt No............................................................

 

Acceptance Sent.................................................Entered on Course roll.......................................

 

CERTIFICATE OF SATISFACTORY COMPLETION OF WATER ACTIVITY COURSE

 

Course Leader.............................................................Date....................../................../...................