Pilgrim Bandits Charity 

Application Form

Name:*
Date of Birth:
 / 
 / 

Contact Details

Address:*
Phone:*
-
E-mail:*
Upload a current Passport Photo:

Passport details - for overseas trips only

Nationality:
Passport Number:
Expiry Date:

Emergency Contact details

Emergency Contact Name:*
Emergency Contact E-mail:*
Emergency Contact Phone:*
-
Emergency Contact Relationship:*

Force services details (please include a copy of your Red Book discharge Cert or it later than 2006 a copy of your certificate of Service

Service Number:*
Current Unit or EX Unit - Include Address:*
PRO or Welfare Officer - include Phone Number:*
Upload a File:
What Qualifications do you hold (i.e. City&Guilds, NVQ,s):

Do you or have you ever suffered from the following? if the Answer is YES please provide further details:

Epilepsy, fits or blackout :*
Blood disorders:*
Diabetes:*
Heart, chest or lung problems:*
Recurrent ear or sinus Problems:*
Anxiety and/or depression:*
Asthma:*
Allergies:*
Additional Info:
Detailed Injury, injuries or condition::*
Medication currently been used:*
Equipment you will require, (Wheelchair - please give Height,Weight and depth):
Other Special requirement e.g. Dietary:

If you are a sufferer of PTDS, please provide a letter from your currant Doctor, that you are fit to take part in any expedition. This letter would also need your Doctors Surgery Stamp on it.

If you are a suffer of PTSD, would you like a carer to accompany you:*

Pilgrim Bandits Charity

RISK ACCEPTANCE FORM

We accept responsibility to make its expeditions as safe as is reasonably practical. However , adventure activities are inherently hazardous and cannot be completely risk free, however hard we try. Accidents can happen without any contributory negligence from the charity or its staff. The Charity can accept no responsibility for loss or damage to personal property or for personal injury not arising as a result of its own act or default.

I understand and accept the above statements and accept that I have a responsibility to take careful note of instructions and to act in a way that minimises the likelihood of injury I am fit for expedition and will inform the charity before the expedition of any special medical conditions that might affect my safety.

I declare that the information entered above is true at the date it was submitted. 

I understand that I am representing the representing the charity Pilgrim Bandits and will do nothing to bring the charity into disrepute. I also agree to wear the charity clothing supplied to help promote the charity when asked.

Print Name:*
Date:*
Word Verification:

Pilgrim Bandits Charity, 17 Barrswood Road, New Milton, Hants, BH25 5HS

Tel : 01425 626598

Charity Number: 1136166