First Name (required)

Surname (required)

Email Address (required)

Date of Birth (dd/mm/yy) (required)

Phone number (required)

Address (required)

Sex (required)

MaleFemale

Height ( Required by Skydive Centre)

Weight ( Required by Skydive Centre)

Nationality (required)

Next of Kin: Name, email and phone number, including country code (required)

Challenge Dates - 2017 (required)

—Please choose an option—June 4th 2017 - University of DurhamSeptember 17th 2017 - University of St AndrewsTBA - University of WarwickTBA - University of the Arts London

If you are volunteering with a University team, please give the name of your Student Ambassador

Are you taking any medication? (required)

YesNo

Please use this section to tell us about any significant current or past medical conditions that we should be aware of: In some circumstances we may require you to get your doctor to sign a medical certificate allowing you to come on the trip.

Do you have any specific dietary requirements or allergies? (required)

YesNo

If yes to the above, please give details.

T-shirt Size (required)
—Please choose an option—SmallMediumLargeExtra large

*I declare that all the information submitted is correct and I understand that I will be directed to Paypal to pay the non-refundable registration fee of £30. I will pay the registration fee within 7 days of receipt or my place will be released back into the system. Registration will only be complete upon receipt of the registration fee. I understand that fundraising must be completed 3 weeks before the date of the skydive. Failure to complete fundraising by this date may result in not being able to participate in the skydive. By submitting this form I accept Anza's Terms and Conditions.

View our Terms & Conditions