CARIBBEAN AWARD SUB-REGIONAL COUNCIL AFFIX ONE PHOTO HERE (Electronic Accepted)
C.A.S.C. EXPEDITION DOMINICA JULY 29-AUGUST 13, 2011 REGISTRATION FORM
Participant Silver Participant Gold
Exp. Assessor Trainee
Staff / Leader
PLEASE READ CAREFULLY AND THEN COMPLETE AS FULLY AS POSSIBLE, USING BLOCK LETTERS. ENCLOSE TWO RECENT PASSPORT SIZE PHOTOGRAPHS OF YOURSELF; ONE SHOULD BE ATTACHED TO THE TOP OF THIS FORM AND THE OTHER TO THE MEDICAL FORM. THE REGISTRATION FEE IS US$200.00. COMPLETED FORMS AND AT LEASE HALF THE REGISTRATION FEE SHOULD BE RETURNED BY AUTHORISED AWARD OFFICIAL TO REACH DOMINICA 1ST MAY. (See information on page 5) NAME: MR. /MRS. /MISS: ……………………………………………………………..……….. ADDRESS: ……………..………………………………………………………………………… ………………………………………………………………………..…….……….. E-MAIL ADDRESS: ……………………………………………………………………………… TEL: …………………………..
STATUS (MARRIED/SINGLE): ……………………..…….
DATE OF BIRTH: ………….………………………………….. NATIONALITY: ……………………………..
AGE: ………………………
HEIGHT:…….…FEET ….… INCH………..
NEXT OF KIN: ………………………………………………………………………………….. ADDRESS:…….…………………………………………………………………………………. ..………………………………………………………………………………………. RELATIONSHIP: ……………………………………………………………………………….. TEL: (HOME) ……………………………………
(WORK) ……………………………….
HAVE YOU TRAVELLED OR LIVED OVERSEAS? 1
YES ………….
NO ……………..
IF YES, LIST COUNTRIES AND DATES: …………………………………………………… …………………………………………………………………………………………………… LIST ANY LANGUAGES YOU SPEAK/WRITE/READ: ……………………………………. …………………………………………………………………………………………………… LIST ANY MUSICAL INSTRUMENT YOU PLAY: …………………………………………. ……………………………………………………………………………………………………
AWARD PROFILE (ie. activities undertaken at the various levels)
SECTIONS
BRONZE
SILVER
GOLD
SERVICE SKILL PHYSICAL REC. EXPEDITION YEAR COMPLETED
LIST DETAILS UNDERTAKEN:
OF
ANY
OTHER
EXPEDITION/EXPLORATIONS
YOU
HAVE
1. …………………………………………………………………………………………………. 2. ………………………………………………………………………………………………… 3. ………………………………………………………………………………………………… IT IS EXPECTED THAT REPRESENTATIVES MIGHT TALK WITH SCHOOL GROUPS, SERVICE CLUBS AND MEDIA. HAVE YOU ANY EXPERIENCE IN PUBLIC SPEAKING? YES: …………
NO: …………
IF YES, LIST ……………………………………………..
…………………………………………………………………………………………………….
2
HAVE YOU UP-TO-DATE CERTIFICATE OR EXPERIENCES IN ANY OF THE FOLLOWING? IF CERTIFIED, STATE AND GIVE DATES. IF NOT, RATE YOURSELF. 1 - GOOD
2 - FAIR
3 - POOR
4 - NO EXPERIENCE
SMALL BOAT HANDLING (INFLATABLE RUBBER BOATS): …………………………….. REPAIR AND MAINTENANCE OF OUTBOARD MOTORS: ………………………………. MARINE RESCUE: ….……………………
LAND RESCUE: ………………………..
SAILING (DINGHY): ……………………
SAILING (YACHT): ……………………
FIRST AID: ……………………………….
LIFE-SAVING: ………………………….
CARPENTRY: ……………………………
ELECTRICAL………………………
PAINTING: ………………………………
PLUMBING: ………………………
SCUBA DIVING: …………………………
COOKING ON WOOD FIRE: …………
HAVE YOU ANY EXPERIENCE IN SURVIVAL TRAINING? …………………………….. CAN YOU SWIM?
YES: …………
NO: …………
IF YES, CAN YOU TREAD WATER FOR FIVE MINUTES? ……………………………….. CAN YOU SWIM TWENTY FIVE YARDS NON-STOP? …………………………………… PHYSICAL PROFILE HOW MANY OF THE FOLLOWING EXERCISES CAN YOU DO IN ONE MINUTE? PUSH-UPS: …………
FULL SQUATS……………
SIT-UPS…………………
WHAT IS YOUR PULSE RATE? …………………… TIME TO RUN A MILE……………... DO YOU EXERCISE REGULARLY? ……………… CAN YOU FREE DIVE?…………….. HAVE YOU FOLLOWING?
TRAINING/EXPERIENCE/QUALIFICATIONS
UNARMED COMBAT: ……....….
BOXING: …..….....
JUDO: …………………………..
KARATE: …………. 3
IN
ANY
OF
THE
WRESTLING: ……….…...
PASSPORT INFORMATION (Please note that passport expires 6 months prior to expiry date) COUNTRY ISSUED: ………………………
PLACE ISSUED: ……….…………………
DATE ISSUED: …………………………….
PASSPORT NUMBER: …………………..
WHAT WILL IT COST YOU TO ATTEND THIS CASC EXPEDITION?
(STATE IN
CURRENCY OF YOUR COUNTRY): ………………………………………………………….. HOW WILL THE COST OF YOUR TRIP BE FUNDED? ……………………………………… WHAT SIZE T-SHIRT DO YOU WEAR?(Circle as appropriate) MEDIUM, LARGE,X-LARGE HOW MANY EXTRAS DO YOU REQUIRE? (PRICE US$10.00): ……………………………
TO BE SIGNED BY APPLICANT AND, IF A MINOR, BY PARENT/GUARDIAN I HEREBY STATE THAT, TO THE BEST OF MY KNOWLEDGE, THE INFORMATION GIVEN IN THIS DOCUMENT IS CORRECT. I UNDERSTAND THAT I AM RESPONSIBLE FOR MAKING MY OWN INSURANCE ARRANGEMENTS WHILST ON THIS VENTURE.
SIGNED…………………………………..
DATE………………………………..
Applicant SIGNED…………………………………..
DATE…………………………………
Parent/Guardian (if a minor) TO BE COMPLETED BY AN AUTHORISED AWARD OFFICIAL THE ABOVE INFORMATION REGARDING ………………………………………………… IS TO THE BEST OF MY KNOWLEDGE TRUE AND CORRECT. OFFICIAL’S SIGNATURE: …………………………………………………………………….. AUTHORITY: ………………………………………………………………………………….. DATE: …………………………………………………………………………………………... 4
COMPLETED FORMS ARE TO BE RETURNED TO: THE DUKE OF EDINBURGH’S AWARD, DOMINICA P.O. BOX 1261 ROSEAU COMMONWEALTH OF DOMINICA Email: deaddom@hotmail.com
Please contact your NAA/IO office for payment information
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