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.Format: (00000 000 000).
Borough residing in:Type here*
Can you confirm that have either a long-term health condition, chronic illness or a mental health condition. If it is found that you have intentionally given false information then you will be liable for the entrance fee.
Trip Information:
1. Will you require a wheelchair or mobility scooter for this trip? (as we need time to book this)
Weight (kg)Type here
Height (ft)Type here
2. Will you be bringing a carer or Personal Assistant?
3. Would you like to bring along any family/friends? (The maximum is 2)
Please specify how many:
4. Would you like a lunch bag?
If yes, specify how many:
Do you have any food allergies or intolerances?
If yes, please list:
(Note: We are a nut allergen-free organisation on all trips.)
Medical conditions:
Do you have a long term health condition?
If yes, please tell us about it here:
i.e epilepsy, heart condition, etc
Emergency Contact:
In the event of an emergency would you like to add a next of kin?
If yes, please list their details below:
(Name, phone number and relation to yourself*)
Additional Information:
Age group:
Ethnicity:
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:
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: