Duke of Edinburgh – Gold – Qualifier and Practice

Attendee Full Name *

Attendee Age *

Attendee Cell Phone *

Attendee Home Phone

Attendee Current School

Next of Kin Name *

Next of Kin Phone *

Medical or Physical Conditions * Yes
No

Intellectual, Social or Behavioural Needs, Conditions or Disorders * Yes
No

Medications * Yes
No

Allergies * Yes
No

If Yes to any of the above, provide detail here:

I consent to be given over-the-counter medication (e.g. panadol, ibuprofen) * Yes
No

Are you able to swim 50 meters? * Yes
No
Not sure

Are you confident in deep water? * Yes
No
Not sure

Are you able to tread water? * Yes
No
Not sure

Are you able to survival float? * Yes
No
Not sure

Are you confident in the sea or open water? * Yes
No
Not sure

I agree to the terms and conditions, and I have read and understood the risk disclosure. * Yes
Yes, but I do not wish to have photos taken of me/my child for promotional purposes
No