Kew Gardens Trip Consent Form

Kew Gardens Trip Consent Form
Participant Information:
Name*

First NameLast Name
Mobile Phone Number*
Please enter a valid phone number.
Borough residing in:Type here*
Trip Information:
1. Will you require a wheelchair or mobility scooter for this trip? (as we need time to book this)*

YesNo
Weight (kg)Type here
Height (ft)Type here
2. Will you be bringing a carer or Personal Assistant?*

YesNo
3. Would you like to bring along your family/friends?*

YesNo
Please specify how many:
4. Would you like a lunch bag?*

YesNo
If yes, specify how many:
Do you have any food allergies?*

YesNo
If yes, please list:
(Note: We are a nut allergen-free organisation on all trips.)
Medical conditions:
Do you have any medical conditions we should be aware of?*

YesNo
If yes, please list:
i.e epilepsy, heart condition, etc
Emergency Contact:
In the event of an emergency would you like to add a next of kin?*

YesNo
If yes, please list their details below:
(Name, phone number and relation to yourself*)
Additional Information:
Age group:*

16-2425-3435-4445-5455-6465+Prefer not to say
Ethnicity:*

White BritishIrishGypsy or Irish TravellerAny other White background, please specify:Mixed/Multiple ethnic groupsWhite and AsianWhite and Black CaribbeanWhite and Black AfricanAny other Mixed/Multiple ethnic background, please specify:Asian/Asian BritishIndianPakistaniBangladeshiChineseAny other Asian background, please specify:Black/African/Caribbean/Black BritishAfricanCarribeanAny other Black/African/Caribbean background, please specify:Other ethnic group, please specify:Prefer not to say
Where did you hear about us:*
Consent:
I hereby give my consent to participate in the trip to Kew Gardens and acknowledge that I understand the information provided above. I understand that I am not required to remain with the group for the entire duration and may explore independently if I wish.
Signature: *

Clear
Date*

DayMonthYear
Thank you for your cooperation! We look forward to an enjoyable trip at Kew Gardens!
Date

DayMonthYear
Date
Should be Empty:

Kew Gardens Trip Consent Form

Participant Information:

Trip Information:

Medical conditions:

Emergency Contact:

Additional Information:

Consent: