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Medical/Consent Form

This form must be filled out for all persons attending and signed by a legal guardian for those under 18. The information given is confidential and is only available to staff who need to know for reasons of safety etc. They are kept for 3 months after each course, and then destroyed.

 

Date: October 26, 2021

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
I certify that I am 19 years of age or older
First Participant's Information

Course Type:

Course Dates:

Mobile Phone

Please give details of any medical conditions that may affect the course member's ability, including advice given by a doctor. Course members are rarely excluded from an activity due to a medical condition, so please do not miss anything out.

Please indicate if the course member will be taking any medication during the course, and who is responsible for it.

Please note Staff are not allowed to administer any medicines whatsoever, and do not have any medications available such as insect creams or aspirin. However, instructors are trained in first aid, carry first aid kits and will look after medications for those under 18 (e.g. inhalers) if written evidence is given that the medication is required.

Dietary Information


If being catered for, please include any special diets, food allergies etc. (e.g. vegetarian, peanut allergy etc).
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

Course Type:

Course Dates:

Mobile Phone

Please give details of any medical conditions that may affect the course member's ability, including advice given by a doctor. Course members are rarely excluded from an activity due to a medical condition, so please do not miss anything out.

Please indicate if the course member will be taking any medication during the course, and who is responsible for it.

Please note Staff are not allowed to administer any medicines whatsoever, and do not have any medications available such as insect creams or aspirin. However, instructors are trained in first aid, carry first aid kits and will look after medications for those under 18 (e.g. inhalers) if written evidence is given that the medication is required.

Dietary Information


If being catered for, please include any special diets, food allergies etc. (e.g. vegetarian, peanut allergy etc).
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

Course Type:

Course Dates:

Mobile Phone

Please give details of any medical conditions that may affect the course member's ability, including advice given by a doctor. Course members are rarely excluded from an activity due to a medical condition, so please do not miss anything out.

Please indicate if the course member will be taking any medication during the course, and who is responsible for it.

Please note Staff are not allowed to administer any medicines whatsoever, and do not have any medications available such as insect creams or aspirin. However, instructors are trained in first aid, carry first aid kits and will look after medications for those under 18 (e.g. inhalers) if written evidence is given that the medication is required.

Dietary Information


If being catered for, please include any special diets, food allergies etc. (e.g. vegetarian, peanut allergy etc).
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

Course Type:

Course Dates:

Mobile Phone

Please give details of any medical conditions that may affect the course member's ability, including advice given by a doctor. Course members are rarely excluded from an activity due to a medical condition, so please do not miss anything out.

Please indicate if the course member will be taking any medication during the course, and who is responsible for it.

Please note Staff are not allowed to administer any medicines whatsoever, and do not have any medications available such as insect creams or aspirin. However, instructors are trained in first aid, carry first aid kits and will look after medications for those under 18 (e.g. inhalers) if written evidence is given that the medication is required.

Dietary Information


If being catered for, please include any special diets, food allergies etc. (e.g. vegetarian, peanut allergy etc).
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

Course Type:

Course Dates:

Mobile Phone

Please give details of any medical conditions that may affect the course member's ability, including advice given by a doctor. Course members are rarely excluded from an activity due to a medical condition, so please do not miss anything out.

Please indicate if the course member will be taking any medication during the course, and who is responsible for it.

Please note Staff are not allowed to administer any medicines whatsoever, and do not have any medications available such as insect creams or aspirin. However, instructors are trained in first aid, carry first aid kits and will look after medications for those under 18 (e.g. inhalers) if written evidence is given that the medication is required.

Dietary Information


If being catered for, please include any special diets, food allergies etc. (e.g. vegetarian, peanut allergy etc).
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

Course Type:

Course Dates:

Mobile Phone

Please give details of any medical conditions that may affect the course member's ability, including advice given by a doctor. Course members are rarely excluded from an activity due to a medical condition, so please do not miss anything out.

Please indicate if the course member will be taking any medication during the course, and who is responsible for it.

Please note Staff are not allowed to administer any medicines whatsoever, and do not have any medications available such as insect creams or aspirin. However, instructors are trained in first aid, carry first aid kits and will look after medications for those under 18 (e.g. inhalers) if written evidence is given that the medication is required.

Dietary Information


If being catered for, please include any special diets, food allergies etc. (e.g. vegetarian, peanut allergy etc).
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

Course Type:

Course Dates:

Mobile Phone

Please give details of any medical conditions that may affect the course member's ability, including advice given by a doctor. Course members are rarely excluded from an activity due to a medical condition, so please do not miss anything out.

Please indicate if the course member will be taking any medication during the course, and who is responsible for it.

Please note Staff are not allowed to administer any medicines whatsoever, and do not have any medications available such as insect creams or aspirin. However, instructors are trained in first aid, carry first aid kits and will look after medications for those under 18 (e.g. inhalers) if written evidence is given that the medication is required.

Dietary Information


If being catered for, please include any special diets, food allergies etc. (e.g. vegetarian, peanut allergy etc).
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

Course Type:

Course Dates:

Mobile Phone

Please give details of any medical conditions that may affect the course member's ability, including advice given by a doctor. Course members are rarely excluded from an activity due to a medical condition, so please do not miss anything out.

Please indicate if the course member will be taking any medication during the course, and who is responsible for it.

Please note Staff are not allowed to administer any medicines whatsoever, and do not have any medications available such as insect creams or aspirin. However, instructors are trained in first aid, carry first aid kits and will look after medications for those under 18 (e.g. inhalers) if written evidence is given that the medication is required.

Dietary Information


If being catered for, please include any special diets, food allergies etc. (e.g. vegetarian, peanut allergy etc).
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

Course Type:

Course Dates:

Mobile Phone

Please give details of any medical conditions that may affect the course member's ability, including advice given by a doctor. Course members are rarely excluded from an activity due to a medical condition, so please do not miss anything out.

Please indicate if the course member will be taking any medication during the course, and who is responsible for it.

Please note Staff are not allowed to administer any medicines whatsoever, and do not have any medications available such as insect creams or aspirin. However, instructors are trained in first aid, carry first aid kits and will look after medications for those under 18 (e.g. inhalers) if written evidence is given that the medication is required.

Dietary Information


If being catered for, please include any special diets, food allergies etc. (e.g. vegetarian, peanut allergy etc).
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

Course Type:

Course Dates:

Mobile Phone

Please give details of any medical conditions that may affect the course member's ability, including advice given by a doctor. Course members are rarely excluded from an activity due to a medical condition, so please do not miss anything out.

Please indicate if the course member will be taking any medication during the course, and who is responsible for it.

Please note Staff are not allowed to administer any medicines whatsoever, and do not have any medications available such as insect creams or aspirin. However, instructors are trained in first aid, carry first aid kits and will look after medications for those under 18 (e.g. inhalers) if written evidence is given that the medication is required.

Dietary Information


If being catered for, please include any special diets, food allergies etc. (e.g. vegetarian, peanut allergy etc).
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
I consent for the person named above to take part in the activities outlined in the itinerary. Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 19 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
I certify that I am 19 years of age or older
Parent or Guardian's Information

Course Type:

Course Dates:

Mobile Phone

Please give details of any medical conditions that may affect the course member's ability, including advice given by a doctor. Course members are rarely excluded from an activity due to a medical condition, so please do not miss anything out.

Please indicate if the course member will be taking any medication during the course, and who is responsible for it.

Please note Staff are not allowed to administer any medicines whatsoever, and do not have any medications available such as insect creams or aspirin. However, instructors are trained in first aid, carry first aid kits and will look after medications for those under 18 (e.g. inhalers) if written evidence is given that the medication is required.

Dietary Information


If being catered for, please include any special diets, food allergies etc. (e.g. vegetarian, peanut allergy etc).
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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