Sea Change-Makers

Course Application Form

Participants interested in the Sea Change~Makers program are required to complete an application form so that we can ensure that the program is a good fit for you and tailor content to participant interests where possible. Your application also helps us to understand your intentions and medical background so we can know how best to support you during the program.

Your personal information is held confidential and never shared with a third party, unless we need to advise course partners (e.g. caterers, dive supervisors) medical concerns, dietary preferences or allergens that may compromise your safety. Our partners hold that information in utmost confidence.

    First Name

    Last Name

    Date of Birth

    Email

    Phone Number

    Home Address

    How did you hear about Sea Change~Makers?

    What motivates you to join Sea Change~Makers?

    What are your goals and intentions for the program? What do you wish to gain by participating?

    What passions, interests, expertise or talents do you bring?

    In which areas of your life are you trying to effect change (whether in yourself or in society)?

    Do you currently serve/work for an organization? If so, what is its name and your role?

    What is going really well with your life, leadership or ‘change-making’ right now?

    Where are you experiencing the greatest hurdles, blocks or challenges?

    What are you looking for to support your growth at this time?


    Some physical activities carried out during this program (e.g. cold-water immersion through snorkelling, shallow water diving or coastal/intertidal walking and mountain backpacking) may be strenuous, hazardous or carry risk of injury. Such hazards may be increased if you have certain physical conditions.
    The purpose of this brief medical questionnaire is to make us aware of these conditions and to ascertain whether they require extra supervision, follow-up or medical advice.

    Do you have any specific dietary preferences and/or acute food intolerances or allergies?
    YESNO
    If YES, please specify and distinguish between 1) dietary preferences 2) medical allergies (incl. severe food intolerances):

    Do you have any medical condition/s that may be made worse by physical exertion (e.g. heart disease, asthma and some lung complaints)?
    YESNO
    If YES, please specify:

    Do you have any medical condition/s that can result in the loss of consciousness? (e.g. including forms of epilepsy, diabetic conditions)
    YESNO
    If YES, please specify:

    Do you have any respiratory condition such as asthma that can be brought on by exposure to cold water or salt water spray/mist?
    YESNO
    If YES, please specify:

    Do you have any other physical and/or emotional conditions, illness, allergies, injuries or personal needs that you feel are important for the facilitators to know about, or current life circumstances (incl. pregnancy) that might prevent you from fully participating in the program?
    YESNO
    If YES, please specify, and how you are supported in working with this:

    I am aware this program may involve physically and emotionally strenuous activities and may increase the health and safety risks to me if I answered ‘YES’ to any of the above.
    Do you feel willing and able to fully commit to the program if admitted?
    If not, please describe what is in the way of that.

    Sea Change~Makers commences on Thursday 7th November on the Cape Peninsula at 13:00 (exact location to be provided later) and finishes on Sunday 17th November at 10:00.

    Sea Change~Makers Plus commences Thursday 7th November on the Cape Peninsula at 13:00 (exact location to be provided later) and finishes on Sunday 24th November at 10:00.

    This is a residential-style course designed to support an immersive group learning experience. We strongly encourage participants to be present and engaged for the entire time (extenuating circumstances understood).
    Can you foresee any obstacles in attending uninterrupted for the duration of the course?
    YESNO
    If YES, please specify:

    Please share any other things that you think are important for us to know at this time. This may also include - but is not limited to - ways in which you identify that you would like us to know about ahead of your participation. (e.g. preferred pronouns, gender identity, orientation, nationality, race/ethnicity, culture, religious affiliation, or any other identities which are important to you and are important for us to be aware of and sensitive to):

    I confirm that I have answered the above questions honestly and accurately.

    Thank you for your responses!

    Once submitted, you will receive an email acknowledging your application and providing banking details so you can make for your 50% deposit to secure your place in the program.

    Please be assured that if, upon reviewing your application, we decide that the course is not a suitable fit for you, your deposit will be refunded in full.