Duke of Edinburgh's Award Open Residential Booking, Medical and Consent form
Important information
This form will be shared with any supervisors & assessors that are involved in your residential. For participants under 18 years of age a parent, or person with parental responsibility, must complete the form
Participant Details
Name
*
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
Date
How would you describe your Gender?
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Emergency Contact
*
First Name
Last Name
Emergency Contact Number
*
-
Area Code
Phone Number
Medical & Dietary Information
Please provide all relevant information as fully as possible
Please give details of any medical conditions. e.g. asthma, diabetes, eplilepsy. Write 'none' if no medical conditions.
*
Please give details of any medication currently prescribed and how often it is taken. (If regular medication is needed please ensure that sufficient is provided). Write 'none' if no medication required.
*
Please give details of any recent medical treatment, or write 'none' if no recent treatment.
*
Please give details of any allergies or write 'none' if no allergies.
*
Please give details of any special dietary requirements or write 'none' if no additional requirements.
*
Please give details of any existing or previous injuries that may affect the participant during the course
*
Does the participant have an up to date tetanus injection?
*
Yes
No
Please provide the name, address & contact details for the participants registered Doctors Surgery.
*
Booking Information
What date is the course beginning on?
*
-
Day
-
Month
Year
Date
Are you happy for us to pass on your name, email and area travelling from to other group members?
*
yes
no
DofE Award Information
EDofE Candidate number
*
Have you completed any other levels of the DofE award?
*
Bronze
Silver
None
DofE group & leader name & contact details. (School, Youth Club, Open Award Centre)
*
DofE Operating Authority
*
If you are booking with a friend please provide their name.
Consent and Health & Safety Statements
Please read the following points carefully before signing this form. If participants are over 18 they can complete & sign the form themselves.
I understand that participants will not be supervised by Reach Outdoors at all times during the residential as participants must at times be self-reliant and unaccompanied. My son / daughter is / I am aware of the responsibility to follow the standards of behaviour and safety instructions explained by the leaders and that they / I must respect the authority of the leaders to ensure the safety of themselves / myself and other group members.
*
I understand the above
I undertake to inform the group leader in writing of any changes in the health of my son / daughter / myself prior to the start date of the activity.
*
I understand the above
I agree that those in charge may give permission for my son /daughter / myself to receive emergency medical treatment if recommended by Doctors.
*
I Agree
I understand that Reach Outdoors Ltd will take all reasonable steps to provide participants with the level of care and safety arrangements as appropriate to the activity undertaking, but I understand that outdoor activities like Climbing / Kayaking / Coasteering can in extremely rare circumstances be dangerous and there is the risk of personal injury and in very extreme cases the possibility of fatality.
*
I understand
I understand that if my son / daughter is / I am physically unfit to take part in the activities they / I can be withdrawn from the residential on the basis of safety.
*
I understand
I understand that Reach Outdoors Ltd has Public Liability Insurance and a copy is available from the Office. I understand no insurance is provided if my son / daughter / I can no longer take part in the booked course or for any loss of damage to personal property during the course. Our insurance does not cover you for inherent risks or client negligence. Whilst not mandatory you may wish to arrange your own personal injury insurance. For your own safety it is imperative that you abide by the decisions of our guides. We reserve the right to make changes to activities and venues as a result of adverse or impending conditions.
*
I understand
I give permission for any photographs taken of my son / daughter / myself during the course to be used for DofE publicity purposes by Reach Outdoors Ltd.
*
yes
no
I confirm that I have read and understand the points above. All information supplied is correct at the date of completing this form. By providing my email address I can confirm that the person named below is responsible for the participant and has completed the form
*
I confirm
Name
*
First Name
Last Name
If you are not the participant what is your relationship to them?
Email
*
example@example.com
Submit
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