Programme Application Form 1 Personal Details2 Course & Parent Details3 Medical Declaration4 Consents Choose the Course/ProgrammeIf there are no suitable dates for the course you are interested in, complete our form to Register Your Interest for future course dates.Choose a Programme*Senior Journey (ages 14-15 years)Junior Journey (ages 11-13 years)Go Wild (ages 7-10 years)Adventure Skills Development (ages 16-18 years)Discover NZ (16-18years)Senior Journey Dates*Please select your preferred course date. If these dates aren't suitable, please fill out our form to Register Your Interest in future dates.14th - 18th December (2020 SJ-HOL-I2)11th - 15th January (2021 SJ-HOL-I1)18th - 22nd January (2021 SJ-HOL-I2)Adventure Skills Development Dates*Please select your preferred course date. If these dates aren't suitable, please fill out our form to Register Your Interest in future dates.13th - 21st January (2021 ASD-HOL-I1)Junior Journey Dates*Please select your preferred course date. If these dates aren't suitable, please fill out our form to Register Your Interest in future dates.11th - 14th January (2021 JJ-HOL-I1)18th - 21st January (2021 JJ-HOL-I2)25th - 28th January (2021 JJ-HOL-I3)Go Wild Dates*Please select your preferred course date. If these dates aren't suitable, please fill out our form to Register Your Interest in future dates.11th - 15th January (2021 GW-HOL-I1)18th - 22nd January (2021 GW-HOL-I2)25th - 29th January (2021 GW-HOL-I3)Discover NZ Dates*Please select your preferred course date. If these dates aren't suitable, please fill out our form to Register Your Interest in future dates.18th - 28th Jan Cultural (2021 DNZ-I1)12th - 22nd Jul Cultural (2021 DNZ-I3)19th - 29th Apr Adventure (2021 DNZ-I2)4th - 14th Oct Adventure (2021 DNZ-I4)6th - 16th Dec Adventure (2021 DNZ-I5)Duke of Edinburgh's AwardAre you counting this programme towards a Duke of Edinburgh Award?YesNoAre you already enrolled in the Award?*YesNoPlease select your award level:*Bronze - Adventurous JourneySilver - Adventurous JourneyGold - Adventurous JourneyGold - ReisdentialGold Residential & Adventurous Journey (for enrolments on Adventure Skills Development only)Are you completing your practice or qualifier component?*PracticeQualifierParticipant's Personal DetailsStudent Name* First Name Last Name Preferred NameDate of Birth* DD MM YYYY Age*Gender*MaleFemaleGender DiverseHome Phone*MobileAddress* Street Address Address Line 2 City ZIP / Postal Code Current School*School Contact Person(Dean or equivalent)School Contact Person's Email: Citizenship/EthnicityCitizenship*New Zealand Citizen (born in New Zealand)New Zealand Permanent Resident (born overseas but have permanent residency)Australian Citizen (born in Australia)OtherPlease tell us what citizenship you hold*What ethnic group do you belong to?*To select more than one option hold the CTRL button down while selecting optionsNew Zealand EuropeanNew Zealand MāoriPacific IslandAsianOtherWhat is your ethnicity?*Iwi (if known)Parent / Caregiver Contact InformationParent Name*Please enter your nameRelationship to participant applying*Home Phone*Parent Mobile*Parent Email* Parent Address* Street Address Address Line 2 City ZIP / Postal Code Student Medical DeclarationPlease note that many WIO programmes operate in remote areas with limited access to medical resources and facilities. If you have ANY pre-existing medical conditions, please provide as much detail as possible. If medical or behaviour information is not declared, WIO reserves the right to not accept students on arrival or may depart students prior to programme completion. It is your responsibility to contact Whenua Iti Outdoors should there be any changes to the below information prior to the course start date. Thank you. Does your child have any medical conditions we may need to know about?*E.g. asthma, epilepsy, diabetes.YesNoMedical Condition Details*Does your child have any allergies?*E.g. bee or wasp stings, penicillin, certain foods.YesNoAllergy Details*Is your child taking any medication?*YesNoDoes your child require assistance with taking this medication?Yes (please give details below)NoMedication Details*Please state which medications you are takingDoes your child have any current or previous injuries or illnesses which may affect their participation?*E.g. dislocations, back injuries, sprains, or broken bones.YesNoInjury or Illness Details*Does your child have any special dietary requirements?*E.g. vegetarian, vegan, gluten free, sugar freeYesNoDietary Requirements Details*On a scale of 1 to 5 how would you rate your childs overall fitness?*1 = Very unfit / 5 = Super fit12345Is your child a confident swimmer?*YesNoPlease give details of your childs swimming capabilities.Is there anything else we should know about your child? For example does your child have any individual learning needs that we need to be aware of? E.g dyspraxia, aspergers, dyslexia, anxiety, fear of heights, claustrophobia*YesNoDetailsRisk Management ConsentWhen taking part in any adventure activity, risks are encountered that could result in emotional and physical injury up to and including fatality. Whenua Iti Outdoors (WIO) manages these risks with the use of highly trained staff who make decisions about acceptable risks, while enabling students to build their skills, knowledge, experience, confidence and judgement. WIO will take all reasonable steps to manage risks to an acceptable level and to set appropriate safety standards. At times WIO staff will make decisions on behalf of the group about the acceptability of certain risks. Students must follow the instructions of staff in regard to safety and risk management. I understand that there are risks associated with activities in the outdoors. I am aware that WIO will take all reasonable steps to manage these risk to an acceptable level and to set appropriate safety standards. Where my child does not comply with the instructions of any WIO staff member in regard to safety or risk management, I acknowledge that WIO may not be held responsible for any outcome.I understand the Risk Management Consent*I, the parent or guardian of the applicant named above, have read, and give my consent to, the risk management policy as outlined above. Yes Media ConsentDuring the course Whenua Iti Outdoors will take photographs. Some of these images (generally group shots) may appear in our publicity material including, but not limited to, Course publications, Facebook, Instagram, newsletter and website material. By signing this declaration, you give Whenua Iti Outdoors permission to use photographs containing the image of your child for this purpose. Individual students will not be named. I give my consent for media use as outlined above*I, the parent or guardian of the applicant named above, agree and give my consent to the media policy as outlined above. Yes No Parental ConsentParent Signoff*I, the parent/guardian of the student applying, state that all information on this form is accurate to the best of my knowledge. I am aware that should medical or other information change that I need to inform Whenua Iti Outdoors. Yes Date* Date Format: DD slash MM slash YYYY NewsletterPlease sign me up to receive regular updates about programmes available at Whenua Iti Outdoors. Yes How did you find out about this programme?* Facebook Instagram Google Search School Friend / Family Community Advertising Other If other, please state:Further Information:If you have any queries or require further information about this course, please use the box below.CommentsThis field is for validation purposes and should be left unchanged. Please complete this form to enrol on a programme with us. Register Your Interest in future dates. We will contact you when they become available. Contact us if you have any questions, or need more information to complete the form. TALK TO US Want to find out more about a programme or have a question for us? Talk to one of our friendly team - we're happy to help.