Sign Up


Below is the sign-up form for the September Cosmonaut Space & Leadership Experience. Complete the form and click "Submit", after which you will be navigated to PayPal to complete payment. You do not need a PayPal account to complete the checkout.

*Please ensure you have a image file of your passport ready, as you will need to upload one to complete this form.

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Information Regarding Your Passport

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Chania

Please make sure the passport is in an image format, e.g. JPEG, PNG, GIF etc. and that it is of a good standard of quality. Please name your file in the following format 'Mr John F Smith.JPG'

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Emergency Contact Details

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Diet Section

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Please note that you are not covered for any pre-existing medical condition – if that needs to be covered, you will need to arrange your own medical insurance.

If you DISAGREE with any of the following, please give us details in writing.

  • I will not be travelling against medical advice.
  • I will not be travelling to have medical treatment.
  • I have not been given a terminal illness prognosis by a registered doctor.
  • I understand and accept that any claims arising directly or indirectly from any medical condition suffered from or diagnosed in the past 18 months will not be covered.
  • I understand and accept that any claims arising directly or indirectly from any medical condition suffered from or diagnosed more than 18 months ago which is not effectively controlled through regular medication, diet or treatment will not be covered.
  • I am not aware of any reason (including non-medical) why a planned trip is likely to be cancelled or cut short e.g. terminal prognosis or illness of a close relative, close business associate or someone else upon whose health my trip depends.
  • I currently reside in the UK.
  • I will not be aged over 74 at the policy start date.

Any heart-related or blood circulatory condition (not including mild well-controlled hypertension suffered in isolation)?

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Any breathing condition (not including mild, well-controlled asthma suffered in isolation)?

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Have you had treatment or hospital consultation for any cancerous condition in the last five years?

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And finally, at any time in the past year, have you been referred to or seen by a hospital doctor or surgeon (other than an A&E Doctor), or needed in-patient treatment in hospital?

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If your answer is yes to any of the above please put it in writing.

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Additional Information

1. Alternative Emergency Contact

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5. Family Doctor

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Parental Consent Form

To be completed by the Parent/Guardian of students under the age of eighteen.


If you are over 18 then tick the box below and skip this section.

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I agree for my Son/Daughter to take part in the visit to Moscow and Star City.

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I agree to my Son’s/Daughter’s participation in the activities described in the itinerary. I acknowledge the need for him/her to behave responsibly.

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1. Medical Information About Your Child

Any conditions requiring medical treatment, including medication.



Please outline any special dietary requirements of your child.



Has your child ever had any problems with common first aid items e.g. Elastoplast, Paracetamol.



Has your child any known allergies?



To the best of your knowledge, your Son/Daughter has not been in contact with any contagious or infectious diseases or suffered from anything in the last four weeks that may be contagious or infectious?



I will inform the Group Leader as soon as possible of any changes in the medical or other circumstances of my child between now and the commencement of the trip.

2. Declaration

I agree to my Son/Daughter receiving medication as instructed and any emergency dental, medical or surgical treatment, including anesthetic or blood transfusion, as considered necessary by the medical authorities present.

I understand the extent and limitations of the insurance cover provided.

I am aware that this visit may include time when the students have some time unsupervised and I agree to this aspect.

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3. Parent/Guardian Information

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Final Step

On clicking submit, you will be securely directed to the PayPal website to complete the payment. *You do not need a PayPal account, you can complete the checkout as a guest user.

Having trouble signing-up? Please don't hesitate to get in touch with us if you are having trouble with the sign-up process: (029) 2071 0295