Aoraki bound application form



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AORAKI BOUND APPLICATION FORM

Please complete all sections and return with a passport sized photo to Aoraki Bound, Te Rūnanga o Ngāi Tahu:

PO Box 13046, Christchurch 8141 / aoraki.bound@ngaitahu.iwi.nz / 0800 KAI TAHU (524 8248) / www.aorakibound.co.nz



  1. PERSONAL DETAILS Te kaitono

Full name

     

Gender

 Male  Female

Date of birth

   /    /     

Age years

  

Citizenship/Residency

 New Zealand Citizen/Resident

 Australian/Pacific Island Citizen

 Other - email enrol@outwardbound.co.nz for an international enrolment form


Ethnicity

 Māori  NZ European/Pākehā  Other - state:      


Kāi Tahu registration

 Tick here if you are registered with Kāi Tahu - provide your registration number:      


Iwi affiliations

     

Kāi Tahu Rūnaka affiliations


 Arowhenua  Awarua  Hokonui  Kaikōura

 Kāti Huirapa ki Puketeraki  Koukourārata  Makaawhio  Moeraki

 Ōnuku  Ōraka Aparima  Ōtākou  Ngāi Tūāhuriri

 Ngāti Waewae  Ngāti Wheke  Te Taumutu  Waihao

 Waihōpai  Wairewa


Postal address

     

Home phone

     

Work phone

     

Mobile phone

     

Fax

     

Email

     

Alternative email

     

School/Education provider


     

Employer/Organisation

     

Job title

     

  1. COURSE DETAILS Te haereka

Preferred Aoraki Bound course dates

 Course 19: 2 - 21 Kahuru February

 Course 20: 2 - 21 Kahuru-kai-paeka March




Name anyone you know attending the same course

     

Where did you hear about the Aoraki Bound course?

 From an Aoraki Bound Graduate Whānau Papatipu Rūnanga Through an email from Ngāi Tahu Te Pānui Rūnaka or Te Karaka magazine Pamphlet Other (please state)

List 3 reasons why the course strongly appeals to you

EG: Ngāi Tahu history, the location, connect with my tribe & identity, leadership skills, career development, adventure sports, etc.

  1. NEXT OF KIN DETAILS Te whanauka tata


 Tick here if your next of kin has done an Outward Bound / Aoraki Bound course - provide their date of birth:    /    /     

Full name

     

Postal address

 Tick here if same as
your address


     

Home phone

     

Work phone

     

Mobile phone

     

Fax

     

Email

     

Alternative email

     

  1. PERSONAL HISTORY Mō te kaitono

CULTURAL KNOWLEDGE Te taha ahurea

To help us plan your course - rate your knowledge of the following cultural practices



Excellent Very good Reasonable Limited No knowledge

Mahika kai food gathering     


Pūrākau history/tradition     

Tikaka/Kawa customs/protocols     

Waka traditional canoes     

Kapa haka performing arts     

Te Reo language     


DIETARY Te kai

 N/A  Gluten free  Dairy free  Vegan

 Vegetarian exclusive  Other food allergies/intolerances - provide details of food types, severity & last reaction:

     



MINIMUM FITNESS Te taha kaha

We must emphasise the physical nature of this course, and that a good level of fitness is required.

Can you comfortably run 3km in under 25 minutes? And walk a full day, on inclined terrain, with a pack?  YES  NO


WATER CONFIDENCE Te kauhoe

Are you confident in water and comfortable putting your head underwater?  YES  NO



SMOKEFREE Auahi kore

Do you smoke?  YES  NO

If YES - how many do you smoke a day       and are you willing to be smokefree on Aoraki Bound?  N/A  YES  NO

MEDICAL Te taha rokoā

State your current: Height       cm Weight       kg if you cannot measure this at home - try your local gym or medical centre

Do you have, or have you ever had, any of the below medical, behavioural or developmental issues?

 ADD/ADHD/Aspergers  Disability - hearing, intellectual, physical, vision

 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 - provide details:

     



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 details of all charges, convictions, sentences and dates:

     



  1. PAYMENT Te utuka

Deposit

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:


  1. TERMS AND CONDITIONS Kā mokamoka


PRIVACY Te tūmataiti

Personal information

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.


Promotional material

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.

Departure

If you depart early or are sent home from your course, your full course fee is not transferrable or refundable.







HEALTH AND WELLBEING Hauora

Safety

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.

Medical form

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.

  1. 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.

Participant’s
signature


SIGN HERE

Participant’s name

     

Today’s date

   /    /     

  1. 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




OFFICE ONLY

Registration




Course code





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