Yacht Outreach Form Company Number of People OneTwo Both people in this application will share a double berth Which Outreach are you applying for? * Outreach 1 - Sheperds Islands - 7-18 June Outreach 2 - Malampa - 2-12 August Outreach 3 - Banks Islands - 15-28 August Other (specify) Person One Name * As it appears on your passport Person One Email * Do you have any allergies to medication? * Yes No Blood Group (if known) Please list vaccinations you have received * Next of Kin * Use full name please Next of Kin email * Next of Kin #2 * Use full name please Next of Kin #2 email * Relationship to you * Next of Kin Phone Number * Next of Kin #2 Relationship to you * Next of Kin #2 Phone Number * Travel Insurance Provider * Insurance contact information * Insurance Policy Number * Does this policy provide emergency medical evacuation? * Yes No I'm not sure Health Information * Chronic Sea Sickness Diabetes Epilepsy Asthma Heart Condition Seizures of any kind Migraines Depression/Anxiety Other (Specify below) Do you suffer from any of these issues? (Select all that apply) Other health conditions we should know about Are you taking regular medication? Please list these along with the reason. Do you require assistance administering your medication? Yes No Yacht outreach is a physically strenuous activity, requiring ladder and stair climbing, balance in unstable ocean, moving through narrow passage ways, wading in water, hiking in hot and humid conditions, and general perseverance in sometimes uncomfortable circumstances. Have you had any major injuries or illnesses in the last six months that may limit your fill participation in the outreach? * Yes No Please describe any other factors which may reduce your capability to be fully involved in the outreach Do you have ALLERGIES to any of the following? * Insect Bites/Stings Medication Food Other Specify the allergy If you have special dietary requirements, please note these here Please note that due to our outreach location it is not always possible to cater to special dietary requirements. While we will do our best to meet your needs, you should plan to bring extra supplementary food from home. We will let you know if we have questions. What level of sailing experience do you have? * None- This is my first (or nearly first) time on a yachtI've spent time on boats, but I wouldn't consider myself a sailorI've done a bit of sailing and can comfortably pitch in without too much directionI'm a competent sailor, but haven't been offshoreI'm a competent sailor and have offshore experience Additional comments How confident are you in the water? * I am not confident at all - I cannot keep myself afloatI can swim a little, but I am not very confidentCompetent swimmerLifeguard/Lifesaving Experience/Could Rescue Someone What level of First aid/Medical Experience do you have? * None Current First Aid Certificate Current Offshore Medical Certificate Medical Professional If you have experience working/volunteering in developing countries, please provide a short description here What skills and experience do you bring to the team? * If the opportunity arises, what kind of projects/programmes would you like to be involved in? * Personal Information - I give V2 Life consent to collect my personal information and share it with their partner yacht captains as they deem appropriate for the planning, operation, safety and security of the yacht outreach 1 * My responsibility to update details - I will inform V2 Life as soon as possible of any changes in the medical or other circumstances between now and the commencement of the event 2 * Emergency Medical Care - I agree to receive any emergency medical, dental, or surgical treatment, including anaesthetic or blood transfusion, as considered necessary by the medical authorities present. 3 * Medical Costs - Any medical costs not covered by travel insurance or governmental health insurers will be paid by me. 4 * Safety and Discipline - I understand that if I am involved in a serious disciplinary problem, including the use of illegal substances, or actions that threaten the safety of others, I will be escorted from the vessel and required to make my own way home. 5 * Right to Information I understand that V2 Life reserves the right to request further details where necessary. 6 * Good Faith and Indemnity - I understand that completion of this form does not place V2 Life under obligation to include me in an outreach, that dates and destinations may vary, and that where payment is made, it is made in good faith that V2 Life will make best efforts to provide outreach opportunities. V2 Life will always act for the safety of volunteers, participants and beneficiaries; weather, maintenance, national events, and medical emergencies are all situations which may require changes to itinerary or outreach activity without warning. 7 * Chain of Command - I understand that participation in a Yacht outreach requires me to follow a specific chain of command for my own safety. When onboard the yacht, I understand that I need to follow direct instructions from the captain for the safety of myself and those on the vessel. When on land, I agree that if they occur, I will follow direct instructions given by the outreach leader for my own safety. 8 *