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Application Form Hands On Development Tour Nepal June 2017

You can either fill the online application here or just download this application , fill it and send the document to handsondevelopmenttours@gmail.com

PERSONAL DETAILS

  • (H)
  • (W)
  • (M)
  • Tick if applying for a passport

NEXT OF KIN - for Emergency Contact

MEDICAL QUALIFICATIONS

Tell us about yourself

Employment

T-SHIRTS

  • How did you hear about the Hands on Development Study Tour 2012-2013?

Fitness Self-Evaluation

  • Please outline your fitness level below. Please note that information you give on this fitness form does not influence your selection on our tour. It merely gives us an idea of your fitness level and helps you plan what you will do to prepare for the expedition.

  • 1. Are you involved in regular sporting or athletic activities?*
    Briefly outline any activities, how regularly you participate, and how long you have been involved.
  • 2. Have you ever been involved in hiking, bush walking, or camping activities? *
    Briefly outline your experiences.
  • 3. Involve in an expedition of this nature requires a fair amount of physical strength and fitness. How do you intend to train or prepare physically for this upcoming challenge? *
  • 4. How would you rate your current level of fitness?*

Medical Information - This will be kept confidential

  • 1. Do you suffered from asthma or any other lung disease? *
  • 2. Do you have allergic reactions (food, chemicals, bites, nuts, stings, etc.)?*
  • 3. Do you have a circulatory condition (e.g. angina) *
  • 4. Do you have diabetes (tablets, insulin or diet controlled)? Please indicate insulin requirements *
  • 5. Do you have joint injury (sprains, strains, dislocations) or other musculoskeletal conditios, i.e. arthritis?*
  • 6. Do you have neurological condition (such as epilepsy)?*
  • 7.Do you have any psychological or psychiatric condition (i.e. Personality disorder, Bipolar, ADD, depression)?*
  • 8. Do you have suffer from any mood swings or specific behaviours that would be important for the Expedition staff to know about so that we can support you on the expedition? Please give details, including medication, support services and management plan*
  • 9. Do you wear contact lenses or require prescription glasses for normal vision?*
  • 10. Have you had surgery that would affect your participation in this trip?*
  • 11. Are you currently having medical treatment?*
  • 12. Do you suffer from vertigo?*
  • 13. Are you on any prescription drugs, including contraceptive pill and homoeopathic drugs?Please give details including dosage and side effects
  • 14. Do you have any sleep disorders (e.g. sleep apnea, walking)?*
  • 15. Do you have any digestive problems (e.g. nausea, vomiting)?*
  • 16. Do you smoke cigarettes? *
  • 16. Are you pregnant?*
  • 17. Do you suffer from migraines or severe/frequent headaches?*
  • 18. Do you have any special dietary requirements Eg. - vegetarian (specify - lacto; vegan, etc)?*
  • 19. Do you have any addictions?*
  • 20. Do you have any abnormal bleeding conditions (anaemia, thalasaemia)?*
  • 21. Are there any other injuries or medical conditions that you believe our staff should be made aware of?*
  • 22. Have you been immunized against diseases in preparation for this expedition or previously?*