Activity Consent Form

Email Address

Phone Number

Date of Birth

Gender

Emergency Contact for duration of course - Name, Relationship to Participant and Contact Information

Please give further details of relevant injuries, illnesses or medication:

Please give any details you feel may be important for us to meet your individual needs: (please note that our staff have additional needs training and can make reasonable adjustments to accommodate most people on our activities, but you must inform us prior to your activity).

Please provide us with GP practice details of the participant:

Any previous relevant experience/qualifications? Please give details:

If you do not wish to receive further information about Dinton Activity Centre or Countryside Service, please tick the box.

If you do not wish for your information to be shared with relevant national governing bodies and/or our commercial partners, please tick this box.

If you do not wish for the participant to be photographed for publicity, please tick the box.

By ticking this box I consent to the use of my electronic signature in lieu of an original signature on paper. You do have the right to request that you sign a paper copy instead, however by ticking this box you are waiving that right. You have the right to submit a written request to obtain a paper copy of the electronic form and electronic signature. 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. Please ensure you update us of any change to your contact details so we can get in touch with any changes, if necessary.

Person taking part in the activity or parent

I have read and agree to the terms and conditions.

Medical Information of course participant