23rd World Scout Jamboree Adult Application SSA Jamboree Office Use Only Date Application Received Jamboree Contingent Number // 23WSJA Please use BLACK ink and PRINT in BLOCK CAPITALS & where necessary indicate choice with an √ Details of Applicant Surname First Name (Full Name - no initials or nicknames) Middle Name Preferred Name Passport-style head & shoulders colour Male Female photograph of applicant to be placed here. Date of Birth // Identity Number Nationality Place of Birth (City/Town) Cellphone Number Home Telephone Number Business Telephone Number Telephone number to be used for daytime contact : Cellphone Home Business *Email Address - * NOTE : THIS ADDRESS WILL BE USED FOR ALL JAMBOREE CORRESPONDENCE Residential Address : Number & Street Name Suburb City Postal Code Postal Address : Number & Street Name / PO Box Number Suburb City Postal Code Home LanguageReligion Poor Average Good Excellent Other Language/s Spoken e.g. Japanese, French etc. Profficiency in English : Single Married Divorced Widow/er Marital Status : Occupation Name of Employer 23rd World Scout Jamboree SCOUTS South Africa Website: www.scouting.org.za Email: [email protected] Telephone: 0860SCOUTS Page 1 of 7 23rd World Scout Jamboree Adult Application Sponsor / Person Responsible for Payment Surname Title First Name (Full Name - no initials or nicknames) Relationship to Applicant Cellphone Number Home Telephone Number Business Telephone Number Telephone number to be used for daytime contact : Cellphone Home Business *Email Address - * NOTE : THIS ADDRESS WILL BE USED FOR ALL JAMBOREE PAYMENT CORRESPONDENCE Postal Address : Number & Street Name / PO Box Number Suburb City Postal Code Scouting / Guiding Record Scout Group / Ranger Crew District Land Sea Air Group Type : Region (Rangers Guiders) Province Current Position Held Cub Brownie Scout Guide Ranger Rover Adult Leader Lay Years' Service in the Movement : Highest Scout / Ranger Guide Advancement Achieved : PLTC PLTU Other Leadership Courses Attended : * NOTE: All adults attending the 23rd WSJ as Jamboree Troop Scouters or International Service Team and Contingent Support Team are required to hold a warrant & have completed the required adult leader training. Preference as an Adult Leader in a Jamboree Troop will be given to Adult Leaders who hold a Scout Wood Badge. Cub Scout GS/CommCub Scout GS/Comm Adult Leader Training Completed : Permit Phase Warrant Cub Scout Rover GS/Comm Date Scout (or Latest) Wood Badge Completed Wood Badge Completed: / / First Water Mountain Mountain Aid ChargeLeadership Awareness Mentoring Specialist Courses Completed: Other : 22WSJ 21WSJ 20WSJ 19WSJ 2011 2007 2003 1999 Previous World Scout Jamborees Attended : Other : Father Mother Brother Sister Son Daughter Please indicate whether any of your family members have also applied to attend 23WSJ : 23rd World Scout Jamboree SCOUTS South Africa Website: www.scouting.org.za Email: [email protected] Telephone: 0860SCOUTS Page 2 of 7 23rd World Scout Jamboree Adult Application Group Scouter/Chairman / Guider or District/Provincial Commissioner's Contact Details Please provide the contact details of your immediate next-in-line SCOUTS South Africa member for reference purposes. Surname Title First Name Contact Telephone Number Scouting Postion Held Email Address Medical Aid Yes No Medical Aid Name / Hospitalisation Scheme Medical Aid? Medical Aid / Hospitalisation Scheme NumberMedical Aid includes International Yes No Travel Cover? Medical Aid International Contact Number Primary Member's Surname Title Primary Member's First Name Primary Member's Contact Telephone Number Primary Member's Identity Number Medical Information Yes No Does the applicant have any allergic reaction to any Medicines, Food, Plants, or Insect Bites ? : Yes No Does the applicant require any chronic or permanent medication ? : Yes No Does the applicant have any disabilities ? : If 'Yes' to any of the above - please provide details; including medication, if required, for the condition : State any important illnesses the applicant has suffered / currently suffers ( e.g. Allergies, Asthma, Diabetes, Epilepsy, etc) Special Dietary Requirments Please indicate any specific dietary requirements : None Halaal Kosher Vegetarian Vegan Food Allergy Other If Yes to 'Food Allergy' or 'Other' - please provide details : 23rd World Scout Jamboree SCOUTS South Africa Website: www.scouting.org.za Email: [email protected] Telephone: 0860SCOUTS Page 3 of 7 23rd World Scout Jamboree Adult Application Details of Next of Kin (Biological Parent / Legal Guardian / Spouse / Other Family Member) Surname Title First Name (Full Name - no initials or nicknames) Relationship to Applicant Cellphone Number Home Telephone Number Business Telephone Number Telephone number to be used for daytime contact : Cellphone Home Business Email Address Emergency Contacts Note: In the event of an emergency, the next of kin will be contacted first followed by other emergency contacts in need. Names of two alternative persons, other than the next of kin , to be contacted in the event of the next of kin being unavailable. Surname First Name Telephone Number Relationship to Applicant Surname First Name Telephone Number Relationship to Applicant Passport Information All Jamboree Contingent Members must be in possession of a valid passport by no later than 31st December 2014 If the applicant is in posession of two passports, South African and a foreign passport, both may be used for travel. As per Japan visa requirements, passport must be valid for a minimum of 9 months after the date of the Jamboree i.e. 10th May 2016 Yes No Yes No Do you hold a valid passport ? : If 'No' Have you applied for a passport ? : Date new passport applied for ? : / / If 'Yes' to the above, Photocopy of passport/s to be attached to this application. If applicant holds two passports then copies of both are to be attached to this application. Yes No Copy of valid passport/s attached ? : South African Passport Information Nationality SOUTH AFRI CAN Passport Number Place of Issue Date of Issue Date of Expiry // // Foreign Passport Information Yes No Does the applicant hold a valid passport of another country to be used for travel to the Jamboree ? : Nationality Passport Number Place of Issue Date of Issue Date of Expiry // // 23rd World Scout Jamboree SCOUTS South Africa Website: www.scouting.org.za Email: [email protected] Telephone: 0860SCOUTS Page 4 of 7 23rd World Scout Jamboree Adult Application SCOUTS South Africa Jamboree Contingent Position Applied For Please note that the the make up of the Jamboree contingent is Jamboree Troop Scouter : based on a specific Scout : Adult ratio. There is one Jamboree Troop Scouter and three Assistant Troop Scouters per Troop of 36 Scouts. Jamboree Assistant Troop Scouter : Please indicate your preference of the SCOUTS South Africa Jamboree Contingent position you would like to apply for, from International Service Team Member : most desireable to the least, 1 being first preference etc. Contingent Support Team : Jamboree Payments and Save-A-Place Deposit This application must be accompanied by a Jamboree Save-A-Place Deposit of R6,000 in order to secure a place as a member of the SCOUTS South Africa Contingent to the 23rd World Scout Jamboree to be held Kirara-hama, Yamaguchi, Japan from Tuesday 28th July to Saturday 8th August 2015. Please note : This application will not be processed until such time as the full Jamboree deposit is received. The full deposit will be refunded in the event of the application as a member of SCOUTS South Africa Jamboree Contingent not being accepted. R500 of the deposit is non-refundable should the applicant withdraw his/her application once accepted as a member of the SCOUTS South Africa Jamboree Contingent. Payment of the R6,000 Jamboree Save-A-Place Deposit will serve as the first payment of the full Jamboree fee and is to be deposited into the following bank account : Bank : Nedbank Branch : Foreshore Cape Town Account Number : 1083278509 Account Name : SCOUTS South Africa Reference : Please use 23WSJ (+ Adult Leader's Name) as Reference Jamboree Correspondence / Address for Submission of Application Forms All Jamboree correspondence must please be addressed to : [email protected] Please note that any Jamboree correspondence sent to any other than the aformentioned email address will not be received by the Jamboree organizers, the 23WSJ Contingent Management Team! This 23WSJ Application Form, together with a copy of the proof of payment of the Jamboree deposit, must be scanned and emailed to the 23WSJ Contingent Management Team on email [email protected]. In addition to the emailed application, a hard copy of the 23WSJ Application Form and all supporting documents along with a copy of the proof of payment of the Jamboree Save-A-Place Deposit, must be sent per mail to the following postal address by the latest 31st May 2014 : 23WSJ SSA Contingent Member Application, Contingent Management Team, SCOUTS South Africa, PO Box 374, Newlands, 7725, Cape Town Closing date for Applications CLOSING DATE FOR ALL 23WSJ APPLICATIONS IS 31st MAY 2014 23rd World Scout Jamboree SCOUTS South Africa Website: www.scouting.org.za Email: [email protected] Telephone: 0860SCOUTS Page 5 of 7 23rd World Scout Jamboree Adult Application Motivation and Recommendation Jamboree Applicant's Initials and Surname *Jamboree Applicant's Scout Group, District or Province (*whichever applicable) Adult Applicant's Personal Motivation The