Enterprize (VIC) – Student App. (2)

What information you need to complete this section

Before you start, it would be best to gather the information you will need to complete this part of your application.

This section includes

• Your contact details and address • A recent Photo of yourself (to upload) • Parent or Legal Guardian details • Emergency Contact details • Sponsoring Rotary Club(s) if any (details) • Your tee shirt size • List of Medical Information and Medications • Asthma and or Allergy Plans (if applicable) • Medicare Number • Name of Medical GP and contact details

Section 2 ”Personal Details"

This is the final section and you should commence this section as soon as you have completed and emailed Part 1. It is helpful to us if both Section 1 and Section 2 are received within a relatively short time. Section 2 is to be filled in online and it contains • more information about you (the applicant) and the Rotary Club (if they have one at this point) • Your (the applicant's) medical details and contact details for your doctor. Once you, (the applicant) and your parent or guardian have gone through the checklist and are satisfied the information entered is complete and correct, press the Submit button. Note: Should you have difficulty in printing or scanning documents, we suggest you ask for assistance at school or at your local library.

Which State do you live in(Required)

Which Voyage would you like to apply for?(Required)

4 day voyage Sat 23rd Sept 2023

4 day voyage Sat 20th Jan 2024

4 day voyage Sat 6th April 2024

Personal Details

Full Legal Name(Required)

First Last

Date of Birth(Required)

Age(Required)

Gender(Required)

Male

Female

Other

Address(Required)

Street Address Address Line 2 City State Post Code

Photo(Required)

Please upload a 'smiling - head and shoulders' photo of yourself.

Accepted file types: jpg, jpeg, png, Max. file size: 1 MB.

Contact Information

Email(Required)

Home Phone

Mobile(Required)

School Attended

Name of school or other educational institution

Required if attending

Contact Person's Name

First Last

Mobile

Did your school recommend you?

Yes

If No - write the Name the other group that recommended you

Phone Number

Email Address

Medical Information

Medical information required on this form and stored in our secure database will only be disclosed to those people who need to know for the applicant's welfare while on the voyage. Under these conditions, I agree to provide all of the information required below in the Medical Information section.

Consent given by(Required)

Applicant (If over 18)

Parent or Guardian

Applicant's Name(Required)

First Last

Date of Birth(Required)

Age(Required)

Gender

Male

Female

Other

Address(Required)

Street Address Address Line 2 City State Post Code

Email Address(Required)

Mobile Contact(Required)

Consent - Parent or Guardian's Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State Post Code

Email(Required)

Phone(Required)

Relationship(Required)

Emergency Contact - a person other than “the parent or legal guardian given above”

Name(Required)

First Last

Relationship(Required)

Other Parent

Family Relation

Family Friend

Phone Number(Required)

Email Address(Required)

Relationship(Required)

Tee Shirt Size(Required)