CHILD MEDICAL QUESTIONNAIRE

CHILD (UNDER 18)

COBNOR ACTIVITIES CENTRE TRUST (CACT) MEDICAL QUESTIONAIRE AND ACTIVITIES CONSENT FORM
Name of participant*

First NameLast Name
Participant's date of birth*

DayMonthYear
Date
Course name (eg: Multi-Activity Week) or School/Group Name*
First day of visit date*

DayMonthYear
Date

Participant's home address*

Street Address

Street Address Line 2

CityCounty

Postcode

Person to be contacted in an emergency*

First NameLast Name
Relationship to participant *
Emergency contact's mobile phone number*
Emergency contact's work telephone number*
Emergency Contact Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name and place of participants surgery*
Contact phone details for participant's doctor*
Contact details for participant's doctor

Area CodePhone Number
YesNo

If yes -please give specific medical advice given*
Please give details of any medication currently being taken and how often it is administered *
If any - Please give details of any recent medical treatment that we need to be aware of *

YesNo
Please provide us with the participants dietary requirements - (If the centre is catering for the school/group) *

PHYSICAL FITNESS - Our activities involve some, or all, of the following:
Bending, lifting, balancing, jumping, falling, climbing, stretching, co-ordination and swimming. If in any doubt, please consult your doctor.
My child can swim 50 metres and is water confidentMy child is water confident and can swim, but I'm not sure how farMy child is a non-swimmer and/or may not be confident in the water
We wish to provide the best experience for your child. Please provide us with any supplementary information that will help support your child with their visit to us
Please add any further information which will help us to ensure your child has a positive experience. In particular, do they have any additional needs of which we should be aware?

YesNo
YesNo

I confirm that I have parental responsibility for the participant and that I consider them fit to participate in the activities at Cobnor Activities Centre Trust (CACT).

I accept that, by their nature, adventure activities may involve some level of risk, which cannot be fully eliminated, and I consent to my child taking part. To help with safety, I understand that all participants are expected to behave in a responsible manner and at all times must take direction from members of CACT staff and follow all instructions or guidance given.

In the event of illness or accident, I consent to any necessary medical treatment, which might include basic first aid and application of dressings and plasters.

If any illness or medical treatment occurs after the return of this form and prior to the activity, I undertake to inform the party leader/booking office in writing. Any other information that may affect my child's safety, or the safety of a participant, or any other persons and/or the organisation of the event, has been provided to Cobnor Activities Centre Trust.
Parents signature:*

Clear
Please PRINT name*
Date*

DayMonthYear
Date
The information you have provided will only be used in connection with your visit to Cobnor Activities Centre Trust. It will only be retained for as long as it is needed to ensure the safety of those attending and for the investigation and reporting of incidents, accidents and near misses. It will be securely disposed of afterwards, in accordance with the Data Protection Act 1998. The data will not be disclosed to any external sources, other than the Adventure Activities Licensing Authority (AALA), National Sporting Governing Bodies or our Auditors without your written consent.
Cobnor Activities Centre Trust, Cobnor Point, Chidham, West Sussex PO18 8TE

sail@cobnor.com : 01243 572791 : cobnor.com

Last reviewed March 2022
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CHILD (UNDER 18)