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Pre-Activity Readiness
Questionnaire and Declaration


At The Real Outdoor Xperience we take your health and safety seriously. We wish to highlight that open and cold water swimming can be a potentially hazardous physical activity and any swimming can lead to risk of injury and even death in exceptional circumstances. 

I agree that The Real Outdoor Xperience are not responsible or liable for any injuries or damages resulting from my participation in any activities. I have read the lake rules and conditions and agree to follow them.

I agree to swim at my own risk and understand the dangers associated with Open and Cold Water Swimming with the potential for serious personal injury and property loss.

I agree that I will swim in the areas stipulated by the organisers. I will swim only during the opening times stipulated and when the lake is deemed safe to swim by ROX.

I certify that I am physically fit, have no pre-existing medical conditions that would affect me swimming outdoors and have completed the health questionnaire. I will alert ROX if my health changes.

The answers provided are accurate and truthful to the best of my knowledge and I do not believe there is any reason I should not take part in the physical activities involved.

I Agree




Please select who will be participating...
AdultMinor
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First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Parent or Guardian's Email Address

Email*

Confirm Email*
SECTION 1 - General Health
Has your doctor ever said you have a heart condition (such as coronary heart disease, congenital heart disease, or vascular disease)?*
No
Yes
Do you feel pain in your chest, shortness of breath or dizziness when you undertake physical activity?*
No
Yes
In the past month have you had chest pain when you are not doing physical exercise?*
No
Yes
Do you lose balance because of dizziness or do you ever lose consciousness?*
No
Yes
Is your doctor currently prescribing drugs for blood pressure or a heart condition or take any medication that may affect you when taking part in physical exertion?*
No
Yes
Are you pregnant?*
No
Yes
Do you suffer from epilepsy?*
No
Yes
Do you suffer from diabetes mellitus and need to take insulin?*
No
Yes
Do you know of any other reason that may affect your ability to take part in physical activity?*
No
Yes

If yes, please state why:
SECTION 2 - Swimming Specific Declaration
Are you able to swim a minimum of 400m in a swimming pool without swimming aids?*
No
Yes
Are you a confident swimmer in deep water?*
No
Yes
Are you able to tread water for a minimum of one minute?*
No
Yes
Have you ever taken part in Open Water Swimming activities or events before?*
No
Yes
Do you have experience of cold water swimming?*
No
Yes
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*

Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 16 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.




By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also 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*
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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