Application form

1. Departure city:__________________________ (We will endeavour to arrange departure from your chosen city. A surcharge may apply.) If you are a student please provide the name of your institution and year of study: ______________________________________ What is your overall level of physical fitness? Excellent Good Fair Poor Do you have any physical conditions that might affect your ability to volunteer? Yes No (You will be required to complete a medical risk assessment prior to travel) Do you have any special dietary requests? ______________________________________ Trip t-shirt size: Men: S M L XL XXL Women: 8 10 12 14 16 EMERGENCY CONTACT INFORMATION Name:______________________________ Relationship: ________________________ Phone:_____________________________ Email:_____________________________ PAYMENT DETAILS: A non-refundable deposit of $200 is required by the 30th of April, 2013 to secure your place in our program. Payment method: I will pay $200 by direct bank transfer, please send details. or I will forward my cheque/money order of $200 to: Student Volunteer Placements International 89 Gundagai street, Coffs Harbour NSW 2450 In signing this I acknowledge I acknowledge that I have read and understood and accept the booking conditions accompanying this booking form and particularly those relating to release and waiver of liability conditions and that I will hold proper travel insurance for the travel. Signed:____________________________________ Date:______________________________________ Application form Please indicate your date preferences: Group 1. 27/11/13 to 22/12/13 Group 2. 04/01/14 to 29/01/14 PERSONAL DETAILS: Mr Mrs Ms Dr First Name:__________________________ Middle Name:_______________________ Last Name:__________________________ (Please write name as it appears on your passport) Street Address:_______________________ Town/Suburb :________________________ State:______________Postcode:_________ Phone: ______________________________ E-mail:______________________________ Date of birth: / / Nationality:___________________________ Passport Number:______________________ Country:______________________________ Place of issue:_________________________ Date of issue: / / Expiry date: / / (Your passport must be valid for at least 6 months after your return date) Accommodation is based on twin share. Is there anyone you would like to share with? _____________________________________ Are you interested in a single room? Yes No (A single supplement will apply and prices will be supplied upon application) Group 3. 26/01/14 to 20/02/14