Black Country Triathletes
Sept 26th Aquathlon Consent Form
Your Details
Your Name
*
First Name
Last Name
Mobile Phone
*
Please enter a valid phone number.
Email
*
example@example.com
Your Relationship to Competitors
*
Second Spectator (if two competitors)
First Name
Last Name
Competitors
Competitor 1
*
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
Date
Competitor 2
First Name
Last Name
Date of Birth
-
Day
-
Month
Year
Date
Competitor 3
First Name
Last Name
Date of Birth
-
Day
-
Month
Year
Date
Medical conditions
Have you or any of the competitors had any of the following conditions in the last 14 days
*
YES
NO
High temperature (above 37.8c)
Fever and tiredness
Persistent cough
Runny Nose
Sneezing
Shortness of breath
Loss or change in sense of smell
Loss or change in sense of taste.
I declare that competitors are medically fit to take part
*
Yes
No
I understand that my details(name, email address) will be kept securely for 21 days and will only be usedfor the purposes of the NHS test and trace initiative and will be securelydestroyed immediately following the 21 day period. Additionally my details may be passed to NHStrack and trace if they are requested by them for the purposes of contact trace
*
Yes
No
I understand that I enter at my own risk and that noperson(s) or organisation(s) will be held responsible for any accident, injury or loss to myself, prior to, during or after the event
*
Clear
Submit
Should be Empty: