Medical Declaration and Consent Form

Each participant is required to submit the Medical Declaration and Consent form below.

Full Name

Address

Phone Number

Date of Birth

Date of Activity (YYYY-MM-DD)

Activity taking part in

Do you have any medical conditions, injuries or allergies which your instructor should be aware of. (required)

Yes

If you answered yes to the previous question, please provide details.

Will this affect your ability to participate in the activity?(required)

Yes

We need to be aware of any medicines that you will be bringing on the day with you and how to administer such medicines in case of emergency eg. Insulin.

May you require sudden treatment during your activity? Please provide details.

Medical Information

Emergency Contact Name

Emergency Contact Phone

Emergency Contact Relationship

<strong>I consider myself to be fit and in good health and there is no medical reason why I should not participate in any activity / adventure offered by my instructor. In the event of an accident during my activity, I give full permission for the relevant instructors, who is suitably trained in First Aid, to administer whatever First Aid treatment they deem appropriate under the circumstances.</strong>(required)

Yes

Please read the following statements carefully:

I realise and accept that mountaineering, water sports and land based activities are activities which carry a danger of personal injury as they take place in uneven / wild and rural terrain. I am aware of and accept these risks and will be responsible for my own actions and involvement in such activities.

While on the activity and in the care of my instructors, I agree to abide by any instructions and decisions made by the instructor regarding individuals and the group as a whole. If I choose to disregard any advice given by the instructor before, during or after the activity, I do so voluntarily and accept liability for all resulting injuries or damage.

I understand that my instructor and the company who is operating the activity accepts no responsibility for accidents or injury to participants or for loss of or damage to personal effects.

Please tick to accept the above statements(required)

I accept and understand.

Marketing and Social Media

<strong>During activities your instructor may take photographs. These photographs may be used for your own personal needs and for marketing purposes in the future. Are you happy for your photograph to be taken.</strong>(required)

Yes

If you’d like to be mentioned in these images on social media, feel free to share your social profiles.

Instagram Profile

Facebook Profile

Consent Declaration

I declare that I have read and understood all of the above information. Please write your name and date in this box below:

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