CSL Activity Health Declaration Form

Activity Health Declaration Form

Please complete one form per person taking part in the activity
Activity Booked
Date of Activity
Name*

PrefixFirst NameLast Name
Date of Birth *

DayMonthYear
Date
Gender
Address*

Street Address

Street Address Line 2

CityCountry

Post Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Emergency contact*

NameRelationship:
Phone Number*
Please enter a valid phone number.
Declaration of fitness to take part in the specified activity. Details of any physical or hidden disabilities, medical conditions (including medication) If none, please write None *
Additional needs (including SENs)
Details (or 'none' If not applicable)
Declaration*
I confirm that the information above is true and I consent to take part in the named activity above*
During your Activity photo / video images may be taken for the purpose of CSL Ltd social media and marketing. If you DO NOT consent to be included in such images, please tick opt out below
Please Note - Your details will not be shared with any other company, apart from the NGB for your course, you will only receive information about CSL Ltd products. See more details in our Data Privacy Policy within the Terms & Conditions page of our website.
Should be Empty: