EXPEDITIONS/EXPLORATIONS
This form is to be used as part of your planning procedures for silver qualification journeys
and copies handed to Mr Bell, Mr Dawkings and your parents 2 weeks prior to your departure.
For Gold Qualifying journeys this form must be submitted to the National Office for approval at
least six weeks prior to the journey taking place.
All parts of this form must be completed – please use BLOCK CAPITALS
The purpose of this form is to determine whether the trip and the participants meet The Duke of
Edinburgh's Hillary Award process requirements.
From: (Name of Operating Authority, School or Club):
St Andrew’s College _____________________________________________________________________________________
Name of The Duke of Edinburgh’s Hillary Award Coordinator
MR. BELL _____________________________________________________________________________________________
Contact Phone Number(s): 9402007 (Daytime) 021 345 481______________________________(Evening)
________________________________________________
Name of Emergency Contact Person: _______________________________________________
Address: ______________________________________________________________
Email Address: ___________________________________________________________
Contact Phone Number(s) ____________________ (Daytime)
______________________________(Evening)
Email address: hbe@stac.school.nz
Please give name and details of the leader of the shadow party / assessor
Name:
_______________________________________________________________
Please verify that this person will be physically tracking the group:
Yes
(Please tick to confirm)
Email address:
Contact Phone Number during the venture:
The above named person is deemed competent to supervise the group under your
organisation’s outdoor safety policies and procedures and has been provided with an
Assessor Checklist.
Yes
(Please tick to confirm)
Nature of proposed venture (please tick):
Practice Venture………… Qualifying Venture…………Expedition…………Exploration…………
Mode of Travel: Foot…………Cycle…………Canoe…………Sailing…………Rowing…………Riding…………
Award Level being undertaken: Bronze…………Silver…………Gold…………
Purpose of Venture (attach a separate sheet if
Type of Report to be submitted (oral, written etc)
necessary)
To be reviewed by (circle appropriate)
Assessor Supervisor Instructor
Mentor
P.T.O
June 2012
Group Members (attach a separate sheet if necessary)
First Name
Surname
Sex
M/F
Age at Date
of Venture in Tick if under
years and
assessment
months
Home Telephone
Number
Previous
Awards
Gained
(B/S or
Direct
Entrant)
Tick if appropriate
preliminary training
has been completed
prior to Practice and
Qualifying Venture
Dates and Areas of Practice Journeys
Undertaken
Location Information (attach a separate sheet if necessary)
Day & Date
Group Location
Grid Ref
Distance
Hours
Height
Gained
Supervisor/Assessor
Location
Grid Ref
Base
Start
Night 1
Night 2
Night 3
Finish
Totals:
Checklist: This is not a comprehensive list, it is a prompt
The nearest DOC office will be contacted to check track conditions and Yes
estimated times?
Each participant will be fully equipped with warm and waterproof clothing Yes
and one full day’s emergency food?
An alternative plan is place in the event of bad weather?
Yes
No
No
No
Map Sheets (if known)
Parents/guardians of the group members will be informed of the Yes
emergency contact person’s address and phone number?
First Aid and Safety Equipment and Food lists and menus have Yes
been checked
Risk Management / Safety Plans have been completed to your Yes
organisation’s requirements?
Declaration: (to be signed by the Assessor):
StAC Approval
I have read and accept the conditions and confirm that they will be fulfilled, including practice journeys. I understand
that each group member is physically able and competent to undertake the venture. I confirm that all Operating
Authority requirements will be fulfilled. I recognise that as the Assessor of the Operating Authority I accept responsibility
for this group.
Date
Signed: ____________________________________
Name:
____________________________________
June 2012
Date: ______________________________________
Position Held:
________________________________
Approved:
No
No
No