OCEAN YOUTH TRUST SOUTH Unit 8, North Meadow, Weevil Lane, Gosport, Hampshire, PO12 1BP Tel 023 ...

OCEAN YOUTH TRUST SOUTH Unit 8, North Meadow, Weevil Lane, Gosport, Hampshire, PO12 1BP Tel 023 9260 2278 email office@oytsouth.org Website www.oytsouth.org

VOYAGE BOOKING FORM i1

This form must be completed and returned as soon as possible with your payment to confirm your berth on the voyage.

DETAILS OF PERSON SAILING

1:Title*

1:Surname*

1: First name*

Known as (if different)

THIS FORM IS TO CONFIRM MY BOOKING ON THE FOLLOWING VOYAGE

1 Voyage No.*

Start date*

Date

Cost £*

Please Enter the Voyage Number,Start date and Cost that you have been given for your voyage

You can pay in full NOW, or pay a DEPOSIT. Choose one of the two following boxes to tick then enter your payment amount.

I will pay in FULL now

1

To Calculate the 25% deposit, divide the cost by 4

I will pay a DEPOSIT now

1

Enter the amount you are paying NOW*

GBPVoyage Fee

Only when your Deposit (or full amount) is paid is your berth confirmed for the voyage.

The PayPal button at the end will let you pay from your PayPal account OR use any Card to pay (Debit or Charge Cards).

Enter as dd/mm/yyyy - Please ensure that you have entered the YEAR of your birth (by using << on the calendar)

Date of birth*

Date

M - F*

Nationality*

1:Address1*

1:Address 2

1:Town/City*

1:County

1:Postcode*

1: Email*

All correspondence will be sent to this address. (if you do not have access to email or telephone No. enter NONE)

1: Tel. day*

1: Tel. eve.*

1: Mobile*

If you do not have a Passport please enter "None". Enter the Town / City where you were born

Passport No.*

2:Town*

Optional information: I consider my ethnicity to be

EMERGENCY CONTACT ON SHORE who must be contactable all day and all night

Relationship to you*

3:Title*

3:Surname*

3:First name*

3:Address 1

3:Address 2

3:Town/City

3:County

3:Postcode

3:Tel. day*

3:Tel. eve.*

3:Mobile*

3:Email*

MEDICAL / BEHAVIOURAL INFORMATION

OYT South need to have all medical and behavioural information necessary to support you on your voyage

Doctor and / or Surgery name*

Doctor's phone*

Have you been diagnosed with or suffered from any of the following in the past 2 years? (please tick as appropriate)If you are being treated with prescribed drugs for any of the conditions noted below you MUST provide full information,including the name of the medication, the dosage and times at which it should be taken

Asthma or bronchitis*

YESNO

Heart condition*

YESNO

Epilepsy (including fits and convulsions)*

YESNO

Diabetes*

YESNO

Fainting or blackouts*

YESNO

Do you sleep walk?*

YESNO

Severe headaches (Migraine)*

YESNO

Attention Deficit / Hyperactivity Disorder (ADHD)*

YESNO

Emotional or Behavioural Difficulties (EBD)*

YESNO

Social Behaviour Problems*

YESNO

Tourette's Syndrome*

YESNO

Asperger's Syndrome*

YESNO

Mental health problems*

YESNO

Recurring health problems*

YESNO

Allergies to any known drugs or medication including Penicillin*

YESNO

Any other allergies e.g. to material, food, insect bites etc.*

YESNO

Would you consider yourself disabled (including visual and/or hearing impairments)?*

YESNO

If you will be taking medication during the voyage, do you need help to administer the correct dose at the correct time?*

YESNO

Any recent contact with contagious diseases or infections?*

YesNO

Are you receiving medical treatment from your family doctor, hospital or specialist?*

YESNO

Have you been given specific medical advice to follow in medical emergencies?*

YESNO

Have you ever received a statement of Special Educational Needs?*

YESNO

Do you have any physical condition that might affect your ability to undertake a voyage?*

YESNO

If female, is it likely that you might be pregnant at the time of the voyage?

YESNO

Do you have a problem with swimming 50M in light clothing ?*

YESNO

Could you be considered unfit to sail in any way?*

YESNO

Have you ever been excluded/dismissed from school/college/work for disruptive/antisocial behaviour?*

YESNO

Have you ever been accused of violent or dishonest/criminal behaviour?*

YESNO

You MUST inform us of any changes to the answers given above before the start of the voyage.

If you have answered YES to any of the questions you MUST provide details below.

Also if you are aware of any additional information or issues of medical, behavioural or other conditions which might affect the performance or safety or wellbeing of the applicant, sea staff or the voyage crew you must provide details below. Depending on their medical condition, you may be asked to provide a doctor's note. If so the OYT South office will tell you once the form has been processed.

Your type of diet*

Other dietary information including allergies

Medical information

Other information (including behavioural and disciplinary)

DECLARATION

The declaration must be made by the applicant if aged 18 or over, or by the parent / guardian if the applicant is under the age of 18 or is a vulnerable adult.

I have provided all relevant details of any medical, physical or other condition which might affect the performance, safety or wellbeing of the applicant, sea staff or the voyage crew*

YESNO

I consent to the applicant being given emergency medical treatment, including the administration of anaesthetic, should it be necessary and authorise OYT South staff to give such permission as may be necessary for such treatment to proceed.*

YESNO

I have read and agree with the Terms and Conditions for Booking a Voyage*

YESNO

I have disclosed all relevant information to Ocean Youth Trust South.*

YESNO

I understand and consent to this information being collected in accordance with Ocean Youth Trust South's privacy policy.*

YESNO

Our terms and conditions can be found here
Our privacy policy can be found here

4:Name*

Relationship*

Date*

Date

Please note: By entering your name above, you are signing to indicate your agreement to the Declaration.

If you are not the applicant, please give your telephone contact number and email address:

4 Day tel. No.

4:Email

All OYT South voyages are 50% subsidised by our generous donors. We send them reports, including photos of crew members, which we also use in OYT South's publicity and fund-raising. To keep our voyage fees as low as possible, we hope you will allow us to use photos taken on your voyage.

I agree to OYT South using my photo for the purposes above*

YESNO

I would like to do my Assessment for the Duke of Edinburgh Residential Gold Award

1

If you have ticked to do your DofE Residential, please give details for your DofE Leader:

Name

Phone

Email

Do you know anyone else who is booking to sail on the same voyage?

YesNo

Your DofE ID number:

Our terms and Conditions can be found here

The PayPal button is in the checkout. If you do not have a PayPal account check out as a Guest to pay using a card.

The first box asks for a country please select United Kingdom