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Participant Information

Please fill out the appropriate form and ensure all information provided is accurate to the best of your knowledge.

If you have any questions, please get in touch with your Booking Point of Contact:
Melissa Symington - msymington@pacificridge.org

Participants Form
Supervising Adult Form

Participants Form

1Personal Details

2Course & Parent Details

3Medical Declaration

4Consents

Your Programme:
Pacific Ridge School:
25 May - 06 June 2020
Booking Point of Contact:
For further information please contact:

Melissa Symington
msymington@pacificridge.org
760-448-9867
Participant's Personal Details
Please complete participant information fields below:
Participant Name*
First Name Last Name
Preferred Name
Passport Number*
Date of Birth*
Age*
Gender*
- Male
- Female
- Gender Diverse
Home Phone Number*
Mobile Contact Number
Email Address*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent / Guardian Contact Information
Parent / Guardian please complete information fields below:
Parent / Guardian Name*
Relationship to participant*
Home Phone Number*
Mobile Contact Number*
Email Address*
Is your address different from the participant's address given above?
- No
- Yes
Parent / Guardian Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Participant Medical Declaration
To be completed by the participant with parent / guardian.

Please note that many ExpedNZ 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.

It is your responsibility to inform your Booking Point of Contact should there be any changes prior to the programme start date to the medical declaration information provided below. Thank you.
Does the participant have any medical conditions we need to know about?*
E.g. asthma, epilepsy, diabetes.
- Yes
- No
Medical Condition Details*
Does the participant have any allergies?*
E.g. bee or wasp stings, penicillin, certain foods.
- Yes
- No
Allergy Details*
Does the participant have any mental health concerns?*
e.g. anxiety, depression (or history of)
- Yes
- No
Mental Health Details*
Does the participant take any medications?*
- Yes
- No
Is assistance required with taking this medication?
- Yes (please give details below)
- No
Medication Details*
Please state which medications you are taking
Does the participant have any current or previous injuries or illnesses which may affect participation in the programme?*
E.g. dislocations, back injuries, sprains, broken bones, glandular fever, pneumonia etc
- Yes
- No
Injury or Illness Details*
Does the participant have any special dietary requirements?*
E.g. vegetarian, vegan, gluten free, sugar free
- Yes
- No
Dietary Requirements Details*
Please indicate on a scale of 1 to 5 overall fitness:*
1 = Very unfit / 5 = Super fit
- 1
- 2
- 3
- 4
- 5
Is the participant a confident swimmer?*
- Yes
- No
Please give details of swimming capabilities.
Is there anything else we need to know about the participant?*
For example general information e.g. fear of heights, claustophobia etc
or specific learning needs e.g. dyspraxia, aspergers, dyslexia etc
- Yes
- No
Details
Risk Management Consent
When taking part in any adventure activity, risks are encountered that could result in emotional and physical injury up to and including fatality. ExpedNZ 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. ExpedNZ will take all reasonable steps to manage risks to an acceptable level and to set appropriate safety standards. At times ExpedNZ staff will make decisions on behalf of the group about the acceptability of certain risks. Participants 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 ExpedNZ will take all reasonable steps to manage these risk to an acceptable level and to set appropriate safety standards. Where the participant does not comply with the instructions of a ExpedNZ staff member in regard to safety or risk management, I acknowledge that ExpedNZ may not be held responsible for any outcome.

ExpedNZ works at a range of sites and locations within New Zealand, at times participants will need to be transported from location to location. ExpedNZ manages a fleet of vehicles and all drivers are certified to carry passengers.
I understand the Risk Management Consent*
I, the parent or guardian of the participant, have read and understood the Risk Management Consent and give my permission for the participant to take part in the programme.
- Yes
Media Consent
During the course ExpedNZ 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. Please indicate if you give ExpedNZ permission to use photographs containing the images of the participant for this purpose. Individual participants will not be named.
Media consent*
I, the parent or guardian of the participant, agree and give media consent for images to be used as outlined above.
- Yes
- No

Parental / Guardian Consent
Parent or Guardian to complete:
Parent / Guardian Signoff*
I, the parent/guardian of the participant, declare 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 the Booking Point of Contact.
- Yes
Date*

Day
Month
Year
Further Information:
If you have any further information you want to declare please use the box below.
Comments
This field is for validation purposes and should be left unchanged.

Supervising Adult Form

1Personal Details

2Medical Declaration

3Consent

Your Programme:
Pacific Ridge School:
25 May - 06 June 2020
Booking Point of Contact:
For further information please contact:

Melissa Symington
msymington@pacificridge.org
760-448-9867
Contact Information
Please complete information fields below:
Full Name*
First Name Last Name
Preferred Name
Passport Number*
Date of Birth*
Gender*
- Male
- Female
- Gender Diverse
Home Phone Number*
Mobile Contact Number
Email Address*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Medical Declaration
Please note that many ExpedNZ 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.

It is your responsibility to inform your Booking Point of Contact should there be any changes prior to the programme start date to the medical declaration information provided below. Thank you.
Do you have any medical conditions we need to know about?*
E.g. asthma, epilepsy, diabetes.
- Yes
- No
Medical Condition Details*
Do you have any allergies?*
E.g. bee or wasp stings, penicillin, certain foods.
- Yes
- No
Allergy Details*
Do you take any medications?*
- Yes
- No
Medication Details*
Please state which medications you are taking
Do you have any current or previous injuries or illnesses which may affect your involvement in the programme?*
E.g. dislocations, back injuries, sprains, broken bones, glandular fever, pneumonia etc
- Yes
- No
Injury or Illness Details*
Do you have any special dietary requirements?*
E.g. vegetarian, vegan, gluten free, sugar free
- Yes
- No
Dietary Requirements Details*
Please indicate on a scale of 1 to 5 overall fitness:*
1 = Very unfit / 5 = Super fit
- 1
- 2
- 3
- 4
- 5
Are you a confident swimmer?*
- Yes
- No
Please give details of swimming capabilities.
Is there anything else we need to know about you?*
For example general information e.g. fear of heights, claustophobia etc
- Yes
- No
Details
Risk Management Consent
When taking part in any adventure activity, risks are encountered that could result in emotional and physical injury up to and including fatality. ExpedNZ manages these risks with the use of highly trained staff who make decisions about acceptable risks, while enabling participants to build their skills, knowledge, experience, confidence and judgement. ExpedNZ will take all reasonable steps to manage risks to an acceptable level and to set appropriate safety standards. At times ExpedNZ staff will make decisions on behalf of the group about the acceptability of certain risks. All group members 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 ExpedNZ will take all reasonable steps to manage these risk to an acceptable level and to set appropriate safety standards. If I do not comply with the instructions of a ExpedNZ staff member in regard to safety or risk management, I acknowledge that ExpedNZ may not be held responsible for any outcome.

ExpedNZ works at a range of sites and locations within New Zealand, at times groups will need to be transported from location to location. ExpedNZ manages a fleet of vehicles and all drivers are certified to carry passengers.
I understand the Risk Management Consent*
I have read and understood the Risk Management Consent statement.
- Yes
Media Consent
During the course ExpedNZ 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. Please indicate if you give ExpedNZ permission to use photographs containing the images of you for this purpose. Individual participants will not be named.
Media consent*
I agree and give media consent for images of me to be used as outlined above.
- Yes
- No

Consent
Supervising Adult Signoff*
I declare 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 the Booking Point of Contact.
- Yes
Date*

Day
Month
Year
Further Information:
If you have any further information you want to declare please use the box below.
Email
This field is for validation purposes and should be left unchanged.

Get In Touch

+64 (0)3 526 7842

info@expednz.com

375 Main Rd, Lower Moutere,
Nelson Tasman, New Zealand
Postal Address:
RD 2, Upper Moutere, 7175
New Zealand

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