Which country?*
Country
Kenya South Africa Thailand Uganda
Check our departure dates
Group Coordinator (if booking with a group)
How did you hear about AV? *
Source
Careers department
Careers Fair
Careers Talk
Publication
The web
Friends
Which one?
Further Info
Title *
Forename *
Surname *
Relationship *
Address *
Post/Zip Code *
Country *
Telephone *
Cell/Mobile *
Email *
Title:
Forename:
Surname:
Relationship:
Telephone:
Cell/Mobile:
Email:
Name in full:
Date of Birth (DD/MM/YY):
Passport Number:
Date of Issue (DD/MM/YY):
Date of Expiry (DD/MM/YY):
Issuing Authority (e.g. UKPA):
Nationality:
Any Dietary Requirements? *
State of Health: *
Can you swim *
Select
Beginner
Intermediate
Advanced
Do you have any allergies to drugs, foods, immunisations? *
Are you under Medical Treatment or taking any medication? *
Have you suffered from Epilepsy, fits, blackouts, diabetes, an eating disorder, nervous and / or mental illness or Asthma in the last 5 years? If so, which? *
Do you have any other medical condition of which we should be aware? If so, what? *
Do you have a criminal record? *
Please provide any additional information that may affect your participation in your project: *
We ask for these details to help us make your project successful.
A non-refundable registration fee of GBP£300 is due with this application form.
If you would like to pay by cheque, please send to Africa & Asia Venture, 10 Market Place, Devizes, Wiltshire, SN10 1HT.
Please select payment type*
Payment
Cheque
Credit/Debit Card
Online Transfer
I CONSENT TO AV OFFICES, IN UK AND ABROAD, AND MY PROJECT HOSTS HOLDING MY PERSONAL DATA.
