General Information
Full Name: Date of birth:
Email: Telephone:
Medical Information
Do you have any medical conditions, for example asthma, diabetes, epilepsy etc
Please give details:
Yes No
Do you have any disabilities or allergies that the centre should be made aware of:
Please give details:
Yes No
Do you have any special requirements?
Please give details:
Yes No
Emergency Contact Details
Full Name: Telephone:
Relationship to you: Mobile:
Safety & Risk Declaration
I understand that all activities by their nature involve an element of risk which could
result in personal injury, illness or death. Whilst the staff team will take rea
sonable
steps to ensure my safety, I understand they can not be held liable for my own actions,
for which I must take responsibility, or for those of a third party.
Yes No
I have completed and submitted a medical consent form. I do not have any medical
conditions or illnesses other than those disclosed on my medical consent form.
Yes No
I understand that I am not to participate in this activity if I am under the inuence of
alcohol or drugs.
Yes No
I understand that all jewellery must be removed or covered before taking part in
any of the activities.
Yes No
I understand that I must take responsi
bility for any personal property or valuables
taken on the activity. Should I lose or damage my property it is not the responsibility
of the centre to replace.
Yes No
I understand that the quality of the water may vary and that there is risk of Weil’s
disease, and if I have any concerns regarding this, I should speak to a staff member.
Yes No
I have been able to read the above relevant Terms and Conditions and agree with these. Yes No
Acknowledgement of Risk Form & Parental Consent
Safety & Risk Declaration: This form is intended to make you aware of the risks
associated with all activities and to help you make an informed decision as to
whether to participate. Signing this form does not (and is not intended to) limit
our obligations to you and does not in any way compromise your legal rights.
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