Experience QRC Application Form

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Welcome to the Experience QRC online application

Please complete and submit the following application. At any time you can use the Save and Continue Later button at the bottom of the page. A link will be emailed to you to click and continue when ready – this link is valid for 30 days.

For information about Experience QRC please click here.

Please note that your information is saved on our server as you enter it.
Applicant Details
Provide your full name as on your passport or birth certificate.
First Name*
Last Name*
Email Address*
Phone Number*
Date of Birth*
DD dash MM dash YYYY
Gender*
Nationality*
Country
Residential Address*
Please provide your current residential address.

Street Address City ZIP / Postal Code Country
Experience QRC Details
Experience Location*
I am applying to Experience QRC
How did you first hear about QRC?*
Other?
Queenstown Dates*
The cost is $299 per person and includes Queenstown airport transfers, two nights accommodation, all meals while in Queenstown and all scheduled activities.
Area of Study Interest - Queenstown*
Are you interested in a particular area of study?
Tai Tokerau Dates*
The cost is $50 per person and includes Kerikeri airport pick up and drop off, one night's accommodation, all meals while in Paihia and all scheduled activities.
Area of Study Interest - Tai Tokerau*
Are you interested in a particular area of study?
School Details
Please provide your school details. We may require a reference from a teacher or careers adviser at your school. Please provide the relevant details.
School Name*
Current School Year*
Teacher / Adviser First Name*
Teacher / Adviser Last Name*
Teacher / Adviser Email*
Teacher / Adviser Phone
Medical Information
Medical Conditions*
Do you have any medical, physical or mental health conditions that may affect your involvement?
Medical Condition Details*
If yes, please state:
Medications*
Are you on / do you carry medication with you (i.e. inhaler for asthma)?
Medication Details*
If yes, please state:
Diet / Allergies*
Do you have any diet / allergy requirements ?
Diet / Allergy Details*
If yes, please state:
Payment Details
We have three payment methods available. Please let us know your preferred option below.
Preferred Payment Method*
School Accounts Consent*
The school agrees to be invoiced for this programme
School Accounts Person*
School Accounts Contact Email*
Payment details will be provided via email.
Payment details will be provided via email.
Declaration
Applicant Consent*
I, the applicant, confirm that the information provided above is true and correct.
If applicant is under 18 years at the time of applying, please include provide parent / guardian details:
Parent / Guardian First Name
Parent / Guardian Last Name
Parent / Guardian Email
Parent / Guardian Phone Number
Questions or Comments?
If you have any additional questions or comments, please include them here.
- Please update me on QRC news and course info
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Experience QRC Application Form

Welcome to the Experience QRC online application

Applicant Details

Experience QRC Details

School Details

Medical Information

Payment Details

Declaration

Experience QRC
Application Form