Sea Survival

POOLE HARBOUR SEA SURVIVAL - COURSE BOOKING FORM

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Name
(To appear on certificate): Mr, Mrs, Miss etc                                                                          

Address:
Post code:                                Email:
Day Tel: Evening Tel:  

Emergency contact details:
Name:
Relationship:
Address:

 Tel Nos:

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

Theory:  Essential 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, STCW 95, 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  
    Yes □
No □ 		  DOB
    Yes □
No □ 		  DOB

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 have read the terms and conditions and I am/we are fit and willing to participate in the course/s. If you object to your data being shared with the RYA for certification purposes please tick here____.  Information is only passed to other schools with you permission if required.

Print Name:                                                   Sign:                                              Date:

Please complete and return this form with the course fee thank you to:  Poole Harbour Sea Survival Ltd, 95 Pilsdon Drive, Canford Heath, Poole, Dorset, BH17 9HT

Cheques payable to:  PHSS

or E-payment to: (Alliance & Leicester)  PHSS sort code 720000   account 02732483

IBAN: GB47 ALEI 7200 0002 7324 83      BIC:  ALEIGB22 

© 2012 Poole Harbour Sea Survival Ltd - All Rights Reserved.