Portland Outdoor Centre Public Activity Session Personal Risk Acknowledgment Disclaimer

Medical Information and Risk Acknowledgment Disclaimer

Portland Outdoor Centre places safety as a top priority, Adventurous Activities involve some risks for the people taking part and our team aim to keep these risks as low as possible. The chances of serious injury are extremely low, but the chance of minor injuries (bruises, bumps and lacerations) are a possible result of taking part in adventurous activities. Portland Outdoor Centre is owned and operated by Activate Outdoors Ltd Co. Reg. No. 3201193
Participants Name*

First NameLast Name
Date of Birth*

DayMonthYear
Date
Email*
example@example.com
Phone Number*

Area CodePhone Number
Activity Choice
Date of Activity (1st day for multi day activities)*

DayMonthYear
Date
Do you have any health conditions that may affect your participation?

AsthmaHistory of recurrent back problemsAny arm, leg or joint problemsAny type of herniaImpairment of sight, hearing or speechRecurring dizzinessMigraine headachesHay fever or allergiesDiabetesEpilepsy, seizures or convulsionsHigh blood pressureHistory of heart attacksRegularly take some form of medicationAny other condition which may affect participation on the activities
Health Conditions details. Please tell us what we need to know. We may need to talk to you for more information.
Are you able to swim 25m?
I am also bringing an under 18 year old
Name of the 1st young person

First NameLast Name
Does this young person have any health conditions that may affect your participation?

AsthmaHistory of recurrent back problemsAny arm, leg or joint problemsAny type of herniaImpairment of sight, hearing or speechRecurring dizzinessMigraine headachesHay fever or allergiesDiabetesEpilepsy, seizures or convulsionsHigh blood pressureHistory of heart attacksRegularly take some form of medicationAny other condition which may affect participation on the activities
Health Conditions details. Please tell us what we need to know. We may need to talk to you for more information.
Are they able to swim 25m?
Name of the 2nd young person

First NameLast Name
Does this young person have any health conditions that may affect your participation?

AsthmaHistory of recurrent back problemsAny arm, leg or joint problemsAny type of herniaImpairment of sight, hearing or speechRecurring dizzinessMigraine headachesHay fever or allergiesDiabetesEpilepsy, seizures or convulsionsHigh blood pressureHistory of heart attacksRegularly take some form of medicationAny other condition which may affect participation on the activities
Health Conditions details. Please tell us what we need to know. We may need to talk to you for more information.
Are they able to swim 25m?
Photographs and videos may be taken by Activate Outdoors Ltd which may be used for future publicity on our website, social media, leaflets and other forms of advertising. Please indicate if you agree to this for you and any under 18s you are bringing.*
Emergency Contact details*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number
I agree to taking part in outdoor activities organised by Activate Outdoors at Portland Outdoor Centre.

Any health or medical information that may affect me participating in these activities is recorded above. Any additional or changes to this information will be declared to the instructor prior to the activity.

I declare that I am aware that outdoor activities carry an element of risk and that I understand those risks and accept them as part of the activity’s enjoyment.

I confirm that no one will participate if under the influence of any Drugs or Alcohol during the activities.

Activate Outdoors will not be held responsible for any loss or damage to your personal belongings
I agree to taking part in outdoor activities organised by Activate Outdoors at Portland Outdoor Centre.

Any health or medical information that may affect me or the young people in my care participating in these activities is recorded above. Any additional or changes to this information will be declared to the instructor prior to the activity.

I declare that I am aware that outdoor activities carry an element of risk and that I understand those risks and accept them as part of the activity’s enjoyment. I am in a position of parental responsibility and accept this risk on behalf of the young people I am bringing.

I confirm that no one will participate if under the influence of any Drugs or Alcohol during the activities.

Activate Outdoors will not be held responsible for any loss or damage to your personal belongings
Date of signature *

DayMonthYear
Date
Signature*

Clear
Covid 19
As you’d expect, we take your health and welfare, and that of our instructors and other staff, very seriously.

Activate Outdoors and its staff will not be liable in any way for any losses, damage or other claims whatsoever arising from the contracting of COVID-19, whilst engaging in any of our activities and/or sessions.

I Understand that in no event will Activate Outdoors be liable for any loss or damage whatsoever without limitation arising from the contracting of COVID-19 Coronavirus whilst engaging in any of their activities and/or sessions and by agreeing to this i thereby release and discharge Activate Outdoors from any claims and liabilities against them due to any COVID-19 Coronavirus circumstance which might occur.

By signing where indicated below you:

· acknowledge, understand and accept that it is not possible to mitigate entirely against the risk of contraction of COVID-19;

·       acknowledge, understand and accept that participation in this session may expose you to a risk of contraction of COVID-19; and

·       acknowledge, consent and agree for all purposes to the above disclaimer and exclusion of liabilities and related claims and accordingly waive, release and discharge us for all purposes from any (potential) claims and liabilities against us due to any COVID-19 Coronavirus circumstance which might occur by virtue of your participation in your session.

Should you or any of your party suspect that you may have contracted and/or been exposed to COVID-19 or be displaying any signs or symptoms suggestive of COVID-19 (however mild) and/or if you are responsible for assisting a person classed in any way as vulnerable for COVID-19 purposes, we respectfully ask you not to attend at this time.

By signing where indicated below you also declare for all purposes that you acknowledge, understand and confirm as follows (and having noted the above disclaimer):

· Members of this group will not attend Portland Outdoor Centre if they are displaying signs or symptoms of the above virus, have tested positive to Covid -19 within the last 10 days or are in a period of isolation in line with current government guidelines.

·       you are aware that engagement in this activity may increase the risks of contracting COVID 19

·       you will adhere to social distancing before, during and after the session;

·       you are aware, should the need arise and that should a member of your group require assistance during activities your instructor may have to break the 2m social distancing rule.
Signature

Clear
By signing this you acknowledge that you have read and understand the Above Covid-19 agreement.
Please verify that you are human*
Should be Empty:

Medical Information and Risk Acknowledgment Disclaimer