Lesley's Rainbow Challenge
Application Form
BEN NEVIS TREK
24th to 28th JULY 2003
APPLICATION FORM, MEDICAL AND CONTACT DETAILS
NAME:
ADDRESS:
Contact Numbers: (Please Include Codes)
TEL. HOME:
TEL. WORK:
MOBILE:
FAX:
EMAIL:
REMEMBER THAT THIS CHALLENGE IS OVER THE COURSE OF A LONG WEEKEND SO PLEASE ENSURE THAT ANY MEDICATIONS OR PRESCRIPTIONS YOU MAY REQUIRE ARE OBTAINED BEFORE THE DAY WE LEAVE
IF YOU HAVE ANY MEDICAL REQUIREMENTS OR CONDITIONS THAT COULD EFFECT THE GROUP PLEASE DETAIL BELOW
MEDICAL CONDITIONS:
CONTACT: IN CASE OF EMERGENCY
NAME:
If the SEND FORM button does not work, please PRINT the completed form and send to:
Cliff Johnson
146 White Hart Lane
Portchester
Fareham
Hants.
PO16 9AZ
Tel: 02392 382956
RELATIONSHIP:
ADDRESS:
TEL. HOME:
MOBILE:
