Medical and Consent Form

Name(required)

Address(required)

Post Code(required)

Date of Birth (dd month yyyy)(required)

Emergency Contact Name(required)

Emergency Contact Phone Number(required)

1 – Have you had any medical conditions that we need to be aware of?(required) Yes (Please provide details below)

Medical Conditions

2 – Do you have any prescribed medication?(required) Yes (Please provide details below)

Prescribed Medication

3 – Have you received a tetanus injection in the last 10 years?(required) Yes

4 – Do you suffer from any allergies?(required) Yes (Please provide details below)

Allergies

5 – Are there any other conditions that we need to be aware of?(required) Yes (Please provide details below)

Any other conditions

6 – I confirm that I will not attend the event if I have any of the COVID-19 symptoms (high temp, new cough or change in taste/smell) or if I am within the self isolation period due to a recent COVID-19 positive test.(required) Confirm

Hill walking and mountaineering are activities with a danger of personal injury or death. Participants in these activities should be aware of and accept these risks and be responsible for their own actions and involvement.
I agree to taking part in the booked activity and I support the need for responsible behaviour during this activity.
I understand that photographs taken and feedback given could be used for publicity purposes.
This data will be held in accordance with current data protection laws, ICO Registration Number ZA787320.

By submitting this form I agree that the information provided is accurate and that I agree to the statements above.

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