Yacht Outreach Form

Order Number

Number of People

One Two

Both people in this application will share a double berth

Which Outreach are you applying for? *

Person One Name *

As it appears on your passport

Person One Email *

Do you have any allergies to medication? *

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? *

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

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? *

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 yacht I've spent time on boats, but I wouldn't consider myself a sailor I've done a bit of sailing and can comfortably pitch in without too much direction I'm a competent sailor, but haven't been offshore I'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 afloat I can swim a little, but I am not very confident Competent swimmer Lifeguard/Lifesaving Experience/Could Rescue Someone

What level of First aid/Medical Experience do you have? *

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 *