Nature and Natter Well-being Walk Consent Form

Nature and Natter Well-being Walk 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*
Trip Information:
1. Will you require a wheelchair or mobility scooter for this trip? (as we need time to book this)
2. Will you be bringing a carer or Personal Assistant?
3. Would you like to bring along your family/friends?
Please specify how many:
4. Would you like a lunch bag?
If yes, specify how many:
Do you have any food allergies?
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?
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?
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 Nature and Natter Well-being Walkand acknowledge that I understand the information provided above.
Signature:
Date

DayMonthYear
Thank you for your cooperation! We look forward to an enjoyable Nature and Natter Well-being Walk!
Date

DayMonthYear
Date
Should be Empty:

Participant Information: