Leader Medical & Disclaimer Form

Page 1 / 3

School Details

School: Wilson's School

Lead Contact: Mr Chris Burton

Activity Dates: 5 & 6th June 2024

Organised Activities with Black Mountain Adventure
Hill Walking
Raft Building
Archery
Land Carting
(for further activity details please see our website)

Participating Leader Details

Participant Name:

Date of Birth:

Telephone Number:

Address:

Gender

If the above details are correct, please proceed to the next page to provide Medical Details.

Medical Information

Page 2 / 3

All persons taking part in activities must complete the following fields as fully as possible prior to activity commencement. All information given will be treated with the strictest confidence.

1. General Medical Details

Do you have any medical conditions? *

Yes No

Are you receiving any medication or treatment? *

Yes No

Do you suffer from allergies? i.e. stings, bites, penicillin, elastoplasts etc *

Yes No

Are you prone to repetitive sports injuries? *

Yes No

Can you swim? *

Yes No

Are there any conditions/details that you wish to inform us about, not covered above? *

Yes No

For equipment purposes i.e. wetsuit, buoyancy aid, please provide your approx. Height (cm), Weight (kg) & Chest (cm) size. *

Emergency Contact Details

Emergency Contact Name:

Emergency Contact Number:

Doctors Name:

Doctors Address:

please provide Surgery Name, Town, Postcode

If the above details are correct, please proceed to the final page - Disclaimer.

Disclaimer & Consent

Page 3 / 3

Whilst we are dedicated to the safety of the clients and endeavour to ensure all activities are operated to a very high standard of safety, there is always an element of unforeseen risk. Anyone wishing to take part in an activity operated by Black Mountain Activities does so with this understanding. All activities offered can be physically demanding therefore, you should be in reasonably good health & physically fit before participating. It is always advisable to seek medical advice if you are unsure about your health.

Understanding & Acceptance of Risk

I (the participant) can confirm that all details given are true and correct and that i am fit and able to participate in the activities.

*

Yes

I (the participant) understand that all activities take place in the outdoors where conditions may be wet, slippery & dangerous. I accept there is an element of risk in the activities i am undertaking and that Black Mountain Activities Ltd will not be held liable for personal injury, death or for loss or damage of property, other than as a result of negligence on the part of Black Mountain Activities Ltd.

*

Yes

I agree to comply with the rules and regulations given by staff at all times and should an instructor feel i am jeopardizing the safety of myself and/or others i will be excluded from the activity and no refund will be given.

*

Yes

Consent

I (the participant) consent to any emergency medical treatment necessary by on-site first aiders or qualified medical respondents in the event of an accident.

*

Yes

I (the participant) consent to Black mountain Activities Ltd taking photographs and video as means of promoting the business through displays, presentations, social media and website.

*

Yes No

Please ensure all details provided within this form are correct and up to date. By submitting this form you are informing Black Mountain Adventure that you fit and well to participate in your chosen activities. If you should have any queries, please give us a call on 01497 847897.

Leader Medical Form (Wilson’s School)

Leader Medical & Disclaimer Form

Page 1 / 3

School Details

Participating Leader Details