BEBINGTON EXPLORER SCOUTS
BRONZE DUKE OF EDINBURGH
PLEASE PRINT DETAILS CLEARLY AND ATTACH A PASSPORT STYLE
PHOTOGRAPH TO THIS FORM (with your name written on the back)
Surname ______________________ forename(s) ____________________________________________
address ______________________________________________________________________________
___________________________________________________ Postcode __________________
Tel No. __________________________________ e-mail
______________________________________
Date of birth ___/___/___ age _______
male
female
Explorer Unit_______________________________ Leader____________________
I would like to enter the Award at
Bronze
Silver
Gold
Signature of applicant _______________________________________
date ___/___/___
Consent of parent or guardian (for young people under 18 years of age)
I agree to my son/daughter/ward participating in The Duke of Edinburgh's Award
Signature of Parent/Guardian ____________________ name _______________________ date
___/___/___
Signature of Award Leader ______________________
name _______________________
Date ___/___/___
The following information is used to help the Award meet the needs of all young people. Only
complete this section if you wish to assist in this way.
Please tick the relevant box
I would describe myself as
Asian or Asian British
Indian
Pakistani
Bangladeshi
Any other
Black or Black British
Chinese
Caribbean
Chinese
African
Mixed
White &
Black
Caribbean
White & Black
African
Any other
White
White &
Asian
I consider myself to have a disability*
Any
other
British
Yes
Irish
Other (specify)
Any
other
No
*As defined by the Disability Discrimination Act as a physical or mental impairment which has a substantial and long-term
adverse effect on a person's ability to carry out normal day-to-day activities.
For office use
Record Book Issue Date ________________UK Ref. No.
Award Enrolment Form 5/05
