Cocos Island - DX-pedition 2010
Group Membership Application Form

I would like to apply for membership of the coming Cocos Island (TI9) - DXpedition

Please completely fill out form and press SEND

1. Personal Information
Title

Birth date
Weight Height
Last name First name
Street address City
State Postal Code
Profession Passport number
Country Email
Phone Fax

Please tell us who has to be informed in case of an emergency:
2. Diving Experience
Certified Diver yes no Diver Insurance
Scuba Agency Certification No.
Diving wanted yes no Diving Ability
# of dives Fishing Experience yes no
Which fish? Where?
3. Please tell us about your home station:
Favourite mode SSB CW RTTY Antennas
TRX Amplifier

Other

 I know how to install antenna systems yes no

I could bring the following equipment with me
4. Please tell us about your radio experience:

Licensed Since

Call

CW-speed WPM

Expeditions

Awards

Contests

5. What could you do for the expedition?

write article

yes no

make photos

yes no

search for sponors

yes no

ship equipment

yes no

6. Please tell us about your general health:
yes no currently suffering from cold yes no

I have had decompression sickness
yes no history of respiratory problems yes no

I have hay fever or alergies
yes no diabetic yes no

I have a collapsed lung
yes no history of high blood preasure yes no

I have had chest surgery
yes no history of seizures, etc. yes no

under care or chronical illness
yes no I have had asthma, emphysema or TBC yes no

I wear contact lenses
yes no history of sinus problems yes no

I am a smoker
yes no nervous system disorder yes no

I am a vegetarian

yes no

I am pregnant

yes no

I need medication (see next field)

Please tell us, which medication you need

Please tell us the address of your physician!

The expedition coordinator is allowed to contact my physician:  yes no

  The above personal information will be kept confidential. The "size" of someone´s station and the "awards" and "experience" will NOT influence our decision. Enthusiastic Ham´s of all nations are very welcome to participate no matter their age, race, religion or political interest.

  By sending this form I state that I am in good mental and physical condition to go on the 16 day trip out on the Pacific Ocean without any medical assistance. I know and agree, that NONE of the expedition members can be held responsible for whatever problem might happen. I participate under my own risk and will have a travel insurance issued in my home country. I know that I can be asked for a medical statement by a doctor.

I absolutely agree to the above!

  

Cocos Island DX-pedition
Apartado 220-6100, Ciudad Colón
Costa Rica, Central America
Phone +506-249-3433
Fax +506-249-4945
Email: ti2hmg@qsl.net

 

 

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