Cape VI Adults - February 2012 Booking Form

Book your spot now for the February camp in the Cape for adults who are blind or visually impaired

We are proud to present you with an online booking form.  Yes, no more inaccessible documents, faxes or paper - you can do it all here online.  Please complete all the fields and click the "submit" button to send us your booking form.

Please note that if any of the required fields are left blank, or if there are any errors, the form will not go through and you will need to change any errors/fill in the item left blank.  Only once you see the 'Thank You' page has your form been submitted.

PERSONAL INFORMATION

Your Name (Required)

Full name(s) and surname please.

Date of birth (Required)

-- 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 / -- January February March April May June July August September October November December / -- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Your E-Mail Address (Required)

Home language (Required)

Afrikaans English IsiNdebele (Ndebele) IsiXhosa (Xhosa) IsiZulu (Zulu) Northern Sotho (Sepedi) Sesotho (Southern Sotho) Setswana (Tswana) SiSwati (Swati) Tshivenda (Venda) Xitsonga (Tsonga) Other Language

Gender (Required)

Male
Female

Have you attended camp before? If yes, when?

Cellphone number

Home number

Work number

Postal Address

Home Address (Required)

Emergency Contact 1 (Required)

Emergency Contact 2 (Required)

CAMP FEES

The cost of the camp is R1650 per person. This includes food, accommodation and activities for the duration of the camp. Please pay via direct deposit into our Standard Bank Account. Email HigherGroundSA@gmail.com for bank details

Payment

I have paid by direct deposit
I still need to pay by direct deposit
Please provide me with other payment options
I need some assistance with camp fees, please let me know about sponsorship options

Proof of payment

If you have made a payment already, kindly upload the proof of payment PDF document or scanned image of the proof of payment here. Please ensure that your file is less than 2 MB.

TRANSPORT

The camp venue is in Stanford (an hour from Hermanus) in the Western Cape. Transport to the venue will be arranged for those travelling from outside of the Cape arriving in Cape Town or Hermanus by bus, train or plane.

MEDICAL INFORMATION

Please complete fully

Cause of Vision Loss

Do you wear:

Glasses
Contact Lenses
Hearing Aids

Mobility - do any of the following apply to you:

I use a wheelchair
I use a walker
I need one-on-one assistance

Will you be bringing a Guide Dog to camp?

Do you have Medical Aid? (Required)

Yes, I do have Medical Aid.
No, I do not have Medical Aid.

Medical Scheme and Membership Number

If you do have Medical Aid please provide the name of your Medical Aid and your Membership Number.

Doctors Name

Doctors Telephone number

Please detail all medical issues eg. Diabetes, Epilepsy, Heart Condition

Please detail any medical/surgical history

Are you aware of any current health problems?

Do you take any medication on a regular basis? (Required)

Yes, I do take some chronic medication
No, I do not take any chronic medication

Please ensure that you bring an adequate supply of medications, food for your guide dog and all personal items - the nearest town is half an hour away

I hereby confirm that all the provided information is accurate, current and true. (Required)

Thank you for your patience and time.  We hope that it has made your booking a more enjoyable experience than before!

Finally, please click the "submit" button.

We will be in touch to confirm your booking.