I agree that I will seek and provide written confirmation from my Primary Health Care Provider (e.g. GP or Neurologist) that the adventure I have chosen is safe for me to undertake, understanding my health status. I confirm that the activity provider is registered, has public liability insurance and is aware of my health condition. I will provide on request written confirmation from the activity provider that they are aware of my condition and the requirements associated. I take full responsibility for my health and safety. While I am receiving a grant from MSNZ and Mastering Mountains there is no liability placed on MSNZ or Mastering Mountains should an accident occur. I will take responsibility for securing my own travel and health insurance to participate in the expedition. I will adhere to all the rules and health and safety policies of the activity provider ensuring that I have read or have had them read to me, and that I have understood the terms and conditions. I agree to fundraise and donate a minimum of 50% of the funds raised beyond the costs of my challenge to Mastering Mountains, to help future grant applicants. I agree speak at a minimum of one public event (as agreed between the Recipient and Grant Provider), talking about my trip and MS, to help change public perceptions, bring hope to others diagnosed and encourage people to be active to improve their well-being and quality of life. Date / / Post your completed application to reach: Mastering Mountains Selection Panel MS Society of NZ PO Box 32124 Christchurch 8147 by 31st May Annually Multiple Sclerosis New Zealand PO Box 32124, Christchurch 8147 0800 MS LINE (67 54 63) info@msnz.org.nz www.msnz.org.nz
I agree that I will seek and provide written confirmation from my Primary Health Care Provider (e.g. GP or Neurologist) that the adventure I have chosen is safe for me to undertake, understanding my health status. I confirm that the activity provider is registered, has public liability insurance and is aware of my health condition. I will provide on request written confirmation from the activity provider that they are aware of my condition and the requirements associated. I take full responsibility for my health and safety. While I am receiving a grant from MSNZ and Mastering Mountains there is no liability placed on MSNZ or Mastering Mountains should an accident occur. I will take responsibility for securing my own travel and health insurance to participate in the expedition. I will adhere to all the rules and health and safety policies of the activity provider ensuring that I have read or have had them read to me, and that I have understood the terms and conditions. I agree to fundraise and donate a minimum of 50% of the funds raised beyond the costs of my challenge to Mastering Mountains, to help future grant applicants. I agree speak at a minimum of one public event (as agreed between the Recipient and Grant Provider), talking about my trip and MS, to help change public perceptions, bring hope to others diagnosed and encourage people to be active to improve their well-being and quality of life. Date / / Post your completed application to reach: Mastering Mountains Selection Panel MS Society of NZ PO Box 32124 Christchurch 8147 by 31st May Annually Multiple Sclerosis New Zealand PO Box 32124, Christchurch 8147 0800 MS LINE (67 54 63) info@msnz.org.nz www.msnz.org.nz