Date:                  ……………………………………………….......................

 

Name:               ………………………………………………..........................................................................................................................................................................

 

Address:            ………………………………………………..........................................................................................................................................................................

                           

………………………………………………...........................................................................................................................................................................

 

Email:                ………………………………………………..........................................................................................................................................................................

 

School:               ……………………………………………….........................................................................................................................................................................

 

Date of Birth    ………………………………………………..

 

Name of Parent / Caregiver:  …………………………………................................................................................................................................................................

 

Phone Number:         ………………………………………………

Name of referee who will support your application: 

 

………………………………………………………………………………..................................................................................................................................................................

 

Phone Number:       …………………………................................................

 

Which programme do you wish to attend?

 

                  Outward Bound

                  Spirit of Adventure

 

What do you know about the programme you have selected?

……………………………………………………………………………...................................................................................................................................................................

.

……………………………………………………………………………...................................................................................................................................................................

 

……………………………………………………………………………...................................................................................................................................................................

 

Why do you wish to attend the programme?

 

……………………………………………………………………………...................................................................................................................................................................

 

……………………………………………………………………………...................................................................................................................................................................

 

……………………………………………………………………………...................................................................................................................................................................

 

……………………………………………………………………………....................................................................................................................................................................

 

Do you agree to the following:

 

The requirement to raise money yourself to contribute to the cost? ($1,000 for Outward Bound or $500 for Spirit of Adventure)
 

To meet the Outward Bound or Spirit of Adventure  Screening Guidelines
 

A qualifying interview with a panel from Kapiti Rotary

 

To speak to the Kapiti Rotary club after completing the programme 

 

 

Signed:  ……………………………………………………

 

Completed by Parent/Caregiver:

 

I support  ……………………………………. attending the programme.

 

 

Signed:   …………………………………………………..