Skipper Information and Health Questionnaire
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Name
*
Address
*
Date of Birth
*
-
Day
-
Month
Year
Date
Email
*
example@example.com
Telephone
*
-
Country Code
Phone Number
Type of boat you are qualified to captain:
*
Power
Sail (Mono)
Sail (Cat)
All
Next of Kin details
Name
*
Address
*
Telephone
*
Doctor's details
Name
*
Address
*
Telephone
*
Passport
Passport number
*
Country of issue
*
Expiry date
*
/
Day
/
Month
Year
Date
Copy of passport upload
*
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of
Qualifications
Please list your qualifications
*
Please also indicate if you are commercially endorsed and that this is up to date (it's worth checking!)
Please upload your relevant qualifications.
*
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Include main quals, ie Yachtmaster, M200,
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of
Date of expiry of Medical, ENG1/ML5
*
Date of expiry of Yachtmaster or equivalent
*
Date of expiry of first aid qualification
*
Insurance
Skipper's third-party liability insurance.
Insurance company
*
Policy number
*
Expiry Date
*
-
Day
-
Month
Year
Date
Insurance policy upload
*
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Drag and drop files here
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Medical History
Do you have any of the following? Or anything we should know about your health and keeping you safe?
*
Asthma
Heart condition
Fits, fainting or blackout?
Severe headaches
Diabetes
Allergies to any known common medicine?
Allergies to any known food?
Other illnesses or disabilities we should know about?
Travel sickness or Sea sickness?
Are you vaccinated against Tetanus in the last 10 years?
Is there any specific medical advice to follow in an emergency?
Other
If you have answered "Yes" to any of the above, please give more details if relevant
During the delivery, images and videos may be taken for promotional use. In the event of any images being taken, I consent to them being used for promotional purposes
*
Please Select
Yes
No
Please ask first
I consider myself to be physically fit enough to be part of a professional yacht crew
*
Please Select
Yes
No
I can swim 50 metres or more
*
Please Select
Yes
No
I do not have any dependency issues with drugs or alcohol
*
Please Select
Yes
No
Any additional information you feel Hornblower Ltd should be aware of that could affect either your safety or that of the vessel or her crew?
*
GDPR
I consent to Hornblower Ltd storing my personal information for use in the administration of yacht deliveries only.
*
Please Select
Yes
Many thanks for providing us with this information.
Please do get in touch if you have any questions.
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