Discover Eden Application Form

Fields marked with a * are required

DISCOVER EDEN APPLICANT DETAILS FORM

Discover Eden Course Name * Discover Eden Course Name * Big 5 Experience Course Ecology Ecuador Ecology Kenya Ecology South Africa Marine Biology Course

Course Date Big 5 *

Course Date Ecology Ecuador*

Course Date Ecology Kenya*

Course Date Ecology South Africa*

Course Date Marine Biology *

Title (Mr, Miss, etc)

First Names (As in passport) *

Surname (As in passport) *

Date of Birth (yyyy/mm/dd) *

Age *

Nationality (As in passport) *

Address *

Postcode (Zip Code) *

Mobile/Cell Number (Incl International Dialling Code) *

Home Phone Number (Incl International Dialling Code)

University Currently Attending *

Year of study in 2024

Do you have any relevant experience or qualifications? * Do you have any relevant experience or qualifications? * Yes No

If Yes, please provide details

What made you want to take part in this program? *

How did you hear about us? *

What are you hoping to gain from this experience? *

Name of university lecturer/course co-ordinator (if known)

Email Address of university lecturer/course co-ordinator (if known)

Do you have any medical or health issues which may affect you during your placement? * Do you have any medical or health issues which may affect you during your placement? * Yes No

If Yes, please specify

Are you taking any medication we should be aware of? * Are you taking any medication we should be aware of? * Yes No

If Yes, please list

Do you have any other special needs that would be helpful for the coordinators to know about? * Do you have any other special needs that would be helpful for the coordinators to know about? * Yes No

If Yes, please describe

Do you have any special dietary requirements? E.g. Allergies or dietary preferences such as vegetarian * Do you have any special dietary requirements? E.g. Allergies or dietary preferences such as vegetarian * Yes No

If Yes, please note

Emergency Contact Title (Mr, Miss, etc)

Emergency Contact First Name *

Emergency Contact Surname *

Emergency Contact Address *

Postcode *

Emergency Contact Home Phone

Emergency Contact Mobile (Cell) Number *

Emergency Contact Email Address *

Any other special information that you feel would be relevant to your application?

Clothing size for unisex t-shirt * Clothing size for unisex t-shirt * Small Medium Large XLarge

I confirm that I will inform of any important changes to my health, medication or needs, and also of any changes to my address or to any of the phone numbers given above. Should I, the applicant, require emergency hospital treatment, I authorise a staff member of Discover Eden Pty ltd to sign on my behalf any written form of consent required by the hospital. In the event of illness or an accident, I give permission for first aid to be administered where considered necessary by a trained first aider, if available or medical treatment to be administered by a suitably qualified medical practitioner. I understand that all travelling, given tasks and activities are done at my own risk. I confirm that I have received, read, and understood a copy of the terms and conditions from Discover Eden Pty ltd. I confirm that I will have valid travel insurance throughout my stay with Discover Eden and that I will present proof of this document on arrival. I confirm that the above details are correct to the best of my knowledge. I confirm that I will inform of any important changes to my health, medication or needs, and also of any changes to my address or to any of the phone numbers given above. Should I, the applicant, require emergency hospital treatment, I authorise a staff member of Discover Eden Pty ltd to sign on my behalf any written form of consent required by the hospital. In the event of illness or an accident, I give permission for first aid to be administered where considered necessary by a trained first aider, if available or medical treatment to be administered by a suitably qualified medical practitioner. I understand that all travelling, given tasks and activities are done at my own risk. I confirm that I have received, read, and understood a copy of the terms and conditions from Discover Eden Pty ltd. I confirm that I will have valid travel insurance throughout my stay with Discover Eden and that I will present proof of this document on arrival. I confirm that the above details are correct to the best of my knowledge. * Select to confirm and have read and agree to the Discover Eden Terms & Conditions

Date (yyyy/mm/dd) *

Name Printed in Full *

Your Email Address *

I would like to receive Discover Eden News & Information I would like to receive Discover Eden News & Information Yes No

13 + 10 =

Dr Mark Brown & Elton du Plooy of Discover Eden