POOLE HARBOUR SEA SURVIVAL - COURSE BOOKING FORM

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Please click here to download our booking terms and conditions in MS Word format

Name:
(To appear on certificate)

Address:

Post code:

Email:

Day Tel:

Evening Tel:

Emergency contact details:

Name:
Relationship:
Address:

Tel No:

Course: Shorebased: VHF (SRC) □ Sea Survival □ First aid □ Radar □ RYA/ISAF □ Diesel □

Theory: Basic Navigation □ Day Skipper □ CS/YM □

Powerboat: Level 1□ Level 2 □ Intermediate □ Advanced □

Motorcruiser: Helmsman □ Day skipper □ Coastal skipper □ Yachtmaster □ ICC <10mtr □ ICC >10mtr □ CEVNI □ Own boat/Electronics/Other □

Course date:

Swimmer:
Yes □
No □

Medical Problems: Please advise (in confidence) of any known medical conditions, illness, injury or allergies which are likely to affect your physical welfare during the course; heart condition, angina, epilepsy, fits, fainting or blackouts, diabetes, giddy spells, asthma, bronchitis, back problems or any other form of disability.

None □

Medication: (in confidence)

Group/Family Details: In addition to the person named above
First Name	Surname	Swimmer	Address if different from the above
		Yes □ No □
		Yes □ No □
		Yes □ No □
		Yes □ No □

Declaration: I certify on behalf of all those named on this form, by whom I am authorised to make this booking, I/we have disclosed any known medical history/problems that are likely to affect our physical welfare during the course (in confidence).

*For the sea survival course I/we agree to partake in a practical liferaft swimming pool session as part of the course. This involves some physical exertion in the deep end of the swimming pool, while wearing a life jacket.

I/we are aware of the potential danger of using live flares during a demonstration and I/we do so at our own risk. I have read the terms and conditions and I am/we are fit and willing to participate in the course/s.

Print Name: Sign: Date:

Making a booking direct from the internet. Please complete and return this form with the course fee either electronically or if posting it drop us an email so we can reserve your place ahead of the form arriving: Poole Harbour Sea Survival Ltd, Marine Skills Centre, Fleets Corner, Nuffield Ind. Estate, Poole, Dorset, BH17 0HL

Cheques payable to: PHSS. E-pay to: (Alliance & Leicester) PHSS sort code 720000 account 02732483

RYA COURSE DATES, FEES AND INFORMATION
RYA COURSE BOOKING FORM
For Additional Course Information Tel: 01202 690505 / Mob: 07766 222797