ACTIVITY PARTICIPANT FORM
Please list all persons attending site
Participants Name
*
First Name
Last Name
Please select your group name
*
Please Select
Future4Me
Lincoln College
PRIVATE LESSON
Lincoln county council
Doggie Dip
Greenbank Milan
Date of visit
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Under 18?
*
YES
NO
Please select status (click all that apply)
*
Staff Member
Student
Participating
Non Participating
Spectator
Please record any pre existing or recent injuries
e.g. recent sprain or broken bone that has mended
Please record any allergies/medical conditions
e.g. nuts, insect stings, anything that may affect participation on the day
Please record any medications carried
e.g. adrenalin pen, inhaler etc
Please mention anything else that may affect your participation or we can help you with on the day.
e.g. limited mobility, ADHD, hearing or sight issues
Please record next of kin contact name
*
Parent or person with parental responsibility (not teaching staff)
Please record next of kin contact tel number
*
Next of Kin phone number
Relationship to participant
*
Relationship of Next of Kin
Please tick to acknowledge each statement below
*
I have declared all known medical conditions
I have declared all know allergies
I have declared all know injuries
I have listed all medications carried/required
I understand that the activities are water and/or land based activities and that all equipment, wet suit, buoyancy aid, helmet, instruction and safety cover will be provided.
I acknowledge that the participant (or my child named above) does not need to be able to swim but must be confident and comfortable in water that may be out of their depth.
I acknowledge that I need to provide suitable footwear to use in the water (such as old trainers), a towel and swim wear to use under the wetsuit provided.
I agree that the participant (or my child named above) can receive immediate care and attention from qualified First Aid staff on site and/or emergency services int he event of an incident requiring such treatment.
I confirm I have made sure inhalers/epi pens/other medications required are on site and staff are aware of there location if required.
I confirm that I am aware that all spectators must remain within the designated areas and not go 'waterside' unless agreed with staff on the day.
I acknowledge that anyone under 16 years of age must be supervised at all times while in the spectator areas.
I confirm that I am aware (and have informed my child named above) that the instructions and guidance given by the instructors on the day must be followed at all times and that they can be excluded from activities if they ignore staff.
I acknowledge that the safety equipment provided must be worn at all times while participating.
I acknowledge that an element of residual risk will remain even after all precautions have been taken to reduce this to an acceptable level for participants. I understand that the company will operate within an established set of guidelines and best practice to safely run all activities it provides, but that accident and injury is still possible but greatly reduced by all participants if they follow the instructions around safety equipment use and activity participation provided on the day.
Signature
Date signed
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Submit
Should be Empty: