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District 1190 Calvert Trust Adventure Week 
24th March - 1st April 2017
DELEGATE/CARER NOMINATION FORM 
Please note that a separate form is required for each delegate and carer. 
This form should be completed by or in the presence of a Rotarian who should 
forward the completed form to the event co-ordinator. 
Name of Club ------------------------------------------------------------------------------- 
Name of Club Contact -------------------------------------------------------------------- 
Email of Club Contact --------------------------------------------------------------------- 
We wish to use our pre-booked place for the following delegate/carer: 

Address ---------------------------------------------------------------------------------------- 
----------------------------------------------------------------- Post Code---------------------- 
Telephone. - - - - - - -- --- - - - - - -- --- ----------- - -----e mai1- -- --------- -------- --- - - - - ---- - --  
Contact information if different from above e.g. parent/guardian/carer
---------------------------------------------------------------------------------------------------------
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Age ------------------------------------- Date of Birth ------------------------------------------- 
Delegates who are under 18 will normally need to be accompanied by an adult 
Nature of Disability of the Delegate ----------------------------------------------------------------- 
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Wheelchair User?----- YES/INO 
Unless the 'delegate is able to get him/herself up, dressed, to breakfast and report to 
the activity leader without help we would expect a carer to accompany him/her. 
Is a Carer Required? (If so you need to arrange this)------ YES/NO 
We need as much information as possible about the level of support needed 
whether or not a carer is coming in support. 
Nature of support needed ---------------------------------------------------------------------- -------
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•

• 

Any further useful information, e.g. dietary requirements, medication taken
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Has the delegate/carer been informed that sleeping will probably be in shared 
accommodation? All rooms are 2, 3 or 4 bedded with en suite facilities, 
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Has the delegate/carer also completed a Medical Form? ---------------------
Has the delegate/carer been asked to supply a photo? -------------------------
Please do not send any money at this time. An invoice will be sent to you 
towards the end of this year. 
Please return the completed Delegate/Carer Form to:
Tony Duncan 
Jopplety How 
Portinscale 
Keswick 
Cumbria 
CA125TX
Or by e-mail to; tonydunc@jopplety.wanadoo.co.uk
Tel; 017687 72285
Before 30th November 2016