Secondary Programme Application Please fill out the form below and ensure all information provided is accurate to the best of your knowledge. Secondary Enrolment Form 1Course & Personal Details2Emergency Contact Details3Medical Declaration4Consents Choose the Course/ProgrammeIf the participant is under the age of 16, please have a parent or supervising adult fill this form in on their behalf.Which region is your school located?* Nelson / Tasman Marlborough West Coast Other Please complete your enrolment via the TOTSTA website: TOTSTA Trades Enrolment Form Choose a Programme* Adventure Tourism Level 2 Adventure Tourism Level 3 Manaaki Tāpoi Level 2 Manaaki Tāpoi Level 3 Predator Control & Conservation Level 3 Environmental Science Level 3 Uniformed Services Level 2 Civil Defence Emergency Response Level 3 Have you attended a Programme with Whenua Iti before?* Yes No Participant's Personal DetailsCurrent School* NSI # (if known) Student Name* First Name Last Name Preferred Name Date of Birth* Day Month Year Age* Gender* Male Female Other Gender How can we support you on the programme?*Please provide further information to help us support you on this programme. Include your preferred name, personal pronoun/s and any other concerns you may have.Contact Phone Number* Address* Street Address Address Line 2 City ZIP / Postal Code Citizenship/EthnicityCitizenship* New Zealand Citizen (born in New Zealand) New Zealand Permanent Resident (born overseas but have permanent residency) Australian Citizen (born in Australia) Other Please 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) Emergency Contact InformationPlease provide contact details that suitable for when you are attending the programme.Name* Relationship to participant applying* Emergency Contact Mobile* Emergency Contact Email Student Medical DeclarationWhenua Iti Outdoors (WIO) aims to accommodate the needs of every individual on our programmes. At times our programmes operate in remote areas with limited access to medical resources and facilities. We ask that you provide as much detail as possible of ANY pre-existing medical conditions or behavioural needs. The programmes on offer are designed to promote personal growth outcomes such as resilience and confidence. They are not designed as therapeutic intervention, if a higher level of support is required please contact us for suitable alternatives. If medical or behavioural information is not declared, we reserve the right to not accept applicants on arrival. Whilst on programme if applicants behaviour or medical issues raise either safety concerns or negatively impact the group, they may be asked to depart the programme early. Should there be any changes to information supplied prior to programme start, it is your responsibility to inform WIO. Thank you kindly for supplying information that allows us to best support applicants needs.I have read the above statement* Yes Do you have any of the following medical conditions?* Diabetes Asthma Epilepsy None of these Diabetes InformationPlease complete the following questions to help us best support you on our programme.Have you been admitted to hospital as a result of diabetes?* Yes No Please provide details of your admission(s) and when this occurred*Do you carry insulin?* Yes No Do you require assistance with administering your medication?* Yes No How do you manage your condition?*Please give details of testing, medication & food requirements as applicable.Asthma InformationPlease complete the following questions to help us best support you on our programme.Have you been admitted to hospital as a result of asthma?* Yes No Please provide details of your admission(s) and when this occurred*Do you carry an inhaler or other forms of medication?* Yes No Do you require assistance with administering your medication?* Yes No How do you manage your condition?*Please include how often you need to take an inhaler, what causes your asthma to worsen (if known) and if it is likely to affect your ability to take part in any activities.Epilepsy InformationPlease complete the following questions to help us best support you on our programme.Have you been admitted to hospital as a result of epilepsy?* Yes No Please provide details of your admission(s) and when this occurred*What form of epilepsy do you have?* When was your last seizure?* How often do seizures occur?* Do you require medication for epilepsy?* Yes No Do you require assistance with administering your medication?* Yes No How do you manage your condition?*Please include how often you need to take medication and the doseage, if there are any likely triggers and which activities it affects you participating in.Other Medical InformationDo you have any other medical condition we may need to know about?* Yes No Please provide further details*Please provide details including frequency, severity, your management plan and any concerns you have for attending the programme. Do you have any allergies?*E.g. bee or wasp stings, penicillin, certain foods. Yes No What are you allergic to?*Have you had an anaphylactic reaction as a result any of these allergies?* Yes No Please provide details of your reaction(s), including your symptoms, and when this occurred.*Do you carry an epipen?* Yes No What is the response plan if you are exposed to the allergen?*Do you have any mental health conditions/concerns?* Yes No What is the condition/concern that affects you?*Please provide details of how you are affected, how often and any triggers you are aware of.Do you take any medication or other treatment?* Yes No Please provide details*If medication, please provide the name, doseage and frequency given. If treatment, please provide further information.Is there any other information you can provide our instructors to best support you on our programme?*Do you take any (other) medication?* Yes No Medication Details*Please state which medications you are taking, the doseage and frequency.Do you require assistance with taking this medication? Yes No Do you have any current or previous injuries or illnesses which may affect your participation?*E.g. dislocations, back injuries, sprains, or broken bones. Yes No Injury or Illness Details*Do you have any special dietary requirements?*E.g. vegetarian, vegan, gluten free, sugar free (If you have a food allergy please provide details in the allergy question above) Yes No Dietary Requirements Details*On a scale of 1 to 5 how would you rate your overall fitness?*1 = Very unfit / 5 = Super fit 1 2 3 4 5 On a scale of 1 to 5 how would you rate your swimming ability?*1 = Non-swimmer / 5 = Very capable & confident 1 2 3 4 5 Please give details of your swimming capabilities.Is there anything else we should know about you? For example do you have any individual learning needs that we need to be aware of? E.g dyspraxia, Asperger's, autism, dyslexia, anxiety, fear of heights, claustrophobia* Yes No Please provide further details*This information will assist our instructor team to support your learning needs during the programme Risk 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 have read, and give my consent to, the risk management policy as outlined above. Yes Behaviour ConsentDuring the course Whenua Iti Outdoors reserves the right to depart a student early, without refund, if undisclosed behavioural issues are deemed to cause safety concerns or unfairly impact the group.I understand the Behaviour Consent* Yes Media ConsentDuring the course Whenua Iti Outdoors may take photographs or video. Some of this media (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 or video 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 agree and give my consent to the media policy as outlined above. Yes No ConsentStudent Agreement*I agree 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 Consent for EvaluationI consent to be texted a link to a short survey following the course to find out how the experience was and the impact it had Yes - Student Yes - Parent/Caregiver Date* 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.Thank you for completing your applicationPlease submit your form below.NameThis field is for validation purposes and should be left unchanged.