Diabetes Serious illness, major operation or knocked unconscious in last year
Epilepsy Mental health - anxiety, depression, bi-polar, schizophrenia, eating disorder
Allergic reactions - bees/wasps/peanuts Treatment/counselling for alcohol or drug use
If YES to any of the above or any other medical concerns - providedetails:
CRIMINAL Te taihara
Do you have any charges pending, convictions, or have you ever had any involvement with Youth Court? YES NO
If YES - provide detailsof all charges, convictions, sentences and dates:
PAYMENT Te utuka
A compulsory, $460, non-refundable deposit is required to secure your place in this course. Please see the separate pūtea tautoko form for deposit payment options.
Paying your course fee
The Aoraki Bound course fee is $4,950 GST inclusive. Full payment of the balance is required 6 weeks before your course start date. Please see the separate Pūtea tautoko form for information on scholarships, raising funds, and payment options.
MY PAYMENT PLAN:
Expected contribution Expected payment date
Funds I can raise myself $
Funds I can raise through my community/workplace* $
Funds I’m requesting from a scholarship ** $
*If your workplace is sponsoring your course costs, please write your place of work, your supervisor’s name, and provide an email for the accounts department, here:
TERMS AND CONDITIONS Kā mokamoka
PRIVACY Te tūmataiti
Your personal information will be held confidential to Outward Bound and Te Rūnanga o Ngāi Tahu, in accordance with the Privacy Act (1993), for the purposes of Outward Bound courses, Te Rūnanga o Ngāi Tahu development opportunities, and associated administration, including promotional activities.
You have the right to see all information held by Outward Bound and Te Rūnanga o Ngāi Tahu, and may ask at any time for that information to be corrected. Ethnicity information is collected for statistical purposes only.
You authorise Outward Bound the right to send a copy of your course report to Te Rūnanga o Ngāi Tahu.
You agree to be interviewed by Ngāi Tahu Communications before and after your course if required.
You agree to write a letter to Te Rūnanga o Ngāi Tahu within 2 weeks of returning from Aoraki Bound detailing what you learning both personally and culturally, how your objectives were met, what you will do differently, how you will share what you learned with whanau, in your workplace and the wider community, play anything else you would like to share.
You authorise Outward Bound and Te Rūnanga o Ngāi Tahu the right to use your name, comments and images (video footage or photographs) that are obtained in relation to your Aoraki Bound participation, including your interview and letter. You authorise Outward Bound and Te Rūnanga o Ngāi Tahu the right to disclose this information to third parties for marketing and public relations purposes. These materials will remain the property of Outward Bound and Te Rūnanga o Ngāi Tahu.
Refunds & Cancellations
Your course fee, less your $460 deposit, is refundable up to 21 days before your course start date.
After this time, your full course fee is not transferrable or refundable. Cancellations must be received in writing.
If you depart early or are sent home from your course, your full course fee is not transferrable or refundable.
HEALTH AND WELLBEING Hauora
Your safety and welfare is our primary concern, however you do participate at your own risk and must accept personal liability for any injury or loss. Note: there are times during your course when you will not be under the direct supervision of staff.
Smoke, drug & alcohol free
Outward Bound has a strict no-smoking policy. No alcohol or non-prescription drugs are permitted.
Your Outward Bound medical form must be completed no more than 3 months before your course end date.
Your Outward Bound medical form is due 8 weeks before your course start date. If your medical is overdue without prior agreement, and it is declined for any reason, the terms and conditions of a cancellation will apply.
Confirmation of your enrolment is subject to approval from both your doctor and Outward Bound. This is to ensure your safety, the safety of others, and quality course outcomes for all. We recommend you book your travel after confirmation of enrolment.
PARTICIPANT’S DECLARATION Kirimana
I have read and agree to the above Terms and Conditions.
I understand that if I do not comply with the above Terms and Conditions, my enrolment may be cancelled or I may be sent home from my course at my own expense.
I understand that, except as expressly permitted by law, if I give any false information, withhold any relevant information, or do not advise of any new relevant information, my enrolment may be cancelled or I may be sent home from my course at my own expense.
I am willing to fully participate in my course, comply with all instructions, and respect others, their beliefs and belongings.
APPLICATION CHECKLIST Rāraki arowhai
I have read the Pūtea Tautoko document
I have completed all areas of the application form
By February 2015, my fitness level will meet the standard required, meaning that I will be fit enough to hike steadily for 6 hours, or run 3km without stopping
I have included my passport photo
If seeking funding, I have filled out the Pūtea Tautoko Scholarship application form below, and included my letter of application
If accepted in the course, I am aware that a deposit of $460 will be required to confirm my place