Enrollment Form

Enrollment Form

Notes:

The applicant should complete this form. If the applicant is under 18, a parent or guardian should complete this form.
Please print clearly in BLOCK LETTERS and tick the appropriate box.
Your name on the course certificate will be typed as it appears on this enrolment form .
Each form is considered valid only with complete information and the applicant's signature on it.
The completed Enrolment Form and a HK$800 deposit should be sent to Outward Bound® Hong Kong, Tai Mong Tsai, Sai Kung, Hong Kong.

1. Personal Data

Applicant's Name (as in passport / travel document )

(English)Surname ______________________________ Other Names __________________

(Chinese) ____________________________________ HKID Card No. ___________________

Passport/Travel Document No. (for overseas course only) _________________________

Date of Birth ________________________

Age (on the first day of course) _____________Years ___________ Months ____________

Home Address _______________________________________________________________
____________________________________________________________________________

Tel. No. (daytime) ___________________ (night) _______________________

Mobile phone/Pager ___________________

Fax No_______________________ Email ________________________

Gender Male Female

Educational Level Primary Seondary University Post-graduate

Name of Employer / School ___________________________________________

Occupation	Finance/Insurance	Student	Medical/Health Services
	Social Welfare	Education	Information Technology
	Government	Unemployed	Construction/Engineering
	Legal Accountancy	Service ( Transport, Tourism, Catering )
	Others (please specify)______________________________________________________

Title/Position	Top/Senior Management
	Manager/Supervisor
	Administrative/Technican / Genernal Staff

Which language(s) can the applicant speak and understand? English Cantonese Mandarin

Is the applicant sponsored by the company ? Yes No

Where did you learn about course information? Friends / Relatives School / Company Internet

Newspaper / Magazines Mailings Road Shows / Exhibitions

Others ________________________________________

Does the applicant have any relevant physical or psychological conditions that we should be aware of ? (please specify) ______________________________________________________________

Is the applicant under medical treatment or on prescribed medication ? (please specify) _______________________________________________________________________________________

Do you have special dietary needs ? (please specify)
_______________________________________________________________________________________

Types of Outward Bound® courses attended BEFORE 1998:

	No. of Times
Children/Youth courses	_________Sea	_________Land
Adult courses of less than 10 days	_________Sea	_________Land
Adult courses of more than 10 days	_________Sea	_________Land
School organized programmes	_________Sea	_________Land
Company organized programmes	_________Sea	_________Land
Others (please specify)	_________Sea	_________Land

Applicant's remarks

2. Emergency Contact

Name (Mr/Mrs/Ms/Miss) ________________________ (Chinese) _____________

Relationship ________________________________________________________

Tel. No. (daytime) __________________ (evening) ________________________

Mobile phone/Pager _______________________

Home address

3. Course Selection

First Choice (course code no.) ______________________________________

Date _________________________ to _____________________________

In case the first-choice is full,the applicant would like to be (tick one):

On the course waiting list

On a different course: Second Choice (course code no) ______________

On a different course: Third Choice (course code no) _______________

4. Insurance

Please enroll me in the Voluntary Personal Accident Insurance (VPAI) Scheme. I understand and agree that no insurance will be effective until the course fee and insurance premium are fully settled before course commencement. I agree to be bound by the Terms and Conditions of Master Policy of the VPAI Scheme
Duration of course not exceeding:	7 days Premium HK$90 14 days Premium HK$160 21 days Premium HK$240

5. Fee Payment

I can afford the full course fee. Enclosed is a deposit of HK$800 or the full course fee.

I would like to apply for the Hong Kong SAR Government / Outward Bound® Subsidies. Enclosed is a deposit of HK$800 and a completed Financial-aid Application Form.

Method of payment

Cheque / BankdraftCheque No. ________________________ Amount enclosed ____________
Cheque No. ________________________ Amount enclosed ____________

Make your cheque payable to the Outward Bound Hong Kong. Print your name and course codenumber on the bach of your cheque / bankdraft. Your insurance premium should be paid together with your full course fee/course fee balance.

Credit Card
Please pay the FULL course fee (deposit already included). Carefully fill in the Credit Card Payment Slip. Include the insurance premium in the total sum if you want to enrol in the VPAI scheme.

Bank-in
Make your payment by direct "bank-in" to the account of the Outward Bound Hong Kong at "The Hongkong and Shanghai Banking Corportion Limited" (Account no. 002 237717 001 .). Receipt No. __________________ Amount _____________ Mail or fax the bank receipt to Outward Bound Hong Kong. Your insurance premium should be paid together with your full course fee / course fee balance.

6. Future Mailings
Outward Bound® Hong Kong seeks your agreement to include your personal information in its mailing list for course information, fund raising events, alumini activities, and keeping you posted about the latest Outward Bound developments. Such data will be treated as confidential and will not be divulged to any other individual or organization.
I agree I do not agree

7. Declaration
I, the undersigned, declare that the information provided is true and complete. I agree that my/the applicant's personal data may be used by theOutward Bound® Hong Kong and its staff for administration, programming and emergencies.

I and the applicant have read and understood the details given in the general information section which includes polices on course transfer and cancellation, refund and leave from the course. I (and the appliciant) agree to abide by the rules for taking part in Outward Bound®? training, in particular, to abstain from alcohol, tobacco and illegal substances to hand my pager / mobile to Outward Bound® Hong Kong for safe-keeping, as well as to participate fully and co-operatively with the staff and others whilst on the course. I/The applicant understand and accept that if the rules or instructions are not observed, I and the applicant may be dismissed from the course.

I (and the appliciant) understand that the course is vigorous and demanding. To the best of my knowledge, there are no medical or other reasons why I/the applicant should not take part in this course. I/The applicant am/is in normal health with no undeclared pre-existing medical or psychological conditions, or allergies.

I agree that, while the staff of the Outward Bound® Hong Kong will exercise reasonable care and supervision, neither Outward Bound® nor its staff, shall be liable for loss, damage, or injury to person or property occasioned by irresponsible acts or behavior of myself/the applicant. I (and the applicant) also understand that should I/the applicant not comply with safety instruction of Outward Bound staff, I may be held liable for any loss, damage or injury to person or property occuring as a result.

I agree ( to my child) (name)___________________________ to take part in the above course. I understand that elements of risk are involved in some of the training and that the organising parties will not be liable for any injuries or accidents. I further agree that should my child requires medical treatment, I consent for him/her to receive whatever treatment needed or determined by a registered doctor..

x___________________________________________ Signature of Applicant or Parent/Guardian (for applicant under 18)	_____________ Date

Name (block letters) ___________________________

For Office Use Only

Applicant's ID No._________________________

Unsuccessful Successful

Government $ __________ OB $ ___________ Others $ __________

Authorized by ____________________________________________

If you have problems printing this form, try downloading the word document of this form instead for submission (use "Save Link As" or "Save As").

CREDIT CARD PAYMENT SLIP
Please charge my credit card for the following course(s):

Course code	Fee per course	Number of places booked	Amount
	HK$		HK$
	HK$		HK$
	HK$		HK$
	HK$		HK$
		Subtotal	HK$
		Insurance (sum of premiums)	HK$
		Total Amount	HK$

Credit Card Number

VISA MASTERCARD

Card Issuing Bank: __________________________________
Card Expiry Date: __________________________________
Cardholder's Name: (Please print) ___________________________________________
Tel (Home): _______________________________
Tel (Office): _______________________________________
Cardholder's Signature: ______________________
Date: _____________________________

For Office Use Only

Authorization Code No._________________________

Date ________________________________________