Adult Medical & Disclaimer Form

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Organiser Details

Group Organiser:

Name of person who has made the booking

Activity Date:

Participant Details

Participant Name:

Date of Birth:

Telephone Number:

Address:

Gender

For medical purposes only

Email:

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

Medical Information

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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. Coronavirus (COVID-19)

Are you currently showing any signs/symptoms of Covid-19?

Yes No

Have you tested positive for Covid-19 in the last 10 days or currently awaiting results of a PCR Test?

Yes No

** You should NOT attend or take part in any activity if you are displaying any signs or symptoms of COVID-19, have tested positive for Covid-19 in the last 10 days or suspect you may have Covid-19.**

2. 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? (if no please state is water confident)

Yes No

Do you have any dietary needs?
i.e. vegetarian, celiac etc (only applicable if ordered packed lunches)

Yes No

Are there any areas we have not yet covered that you feel may be relevant?

Yes No

For equipment purposes i.e. wetsuits, buoyancy aids please provide your approx. Height, Weight, Chest Size.

Emergency Contact Details

Emergency Contact Name:

Emergency Contact Number:

Doctors Name:

Surgery:

please provide Surgery Name, Town, Postcode

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

Disclaimer & Consent

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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.

Coronavirus (Covid-19)-You should NOT attend or take part in any activity if you are displaying signs/symptoms of COVID-19 , have tested positive for Covid-19 in the last 10 days or suspect you may have Covid-19. For the safety of you, your friends/family and Black Mountain staff you will need to follow distancing guidelines at all times when at the centre or on activities. You will also need to wash your hands regularly or use hand sanitiser and you will be required you to wear a face mask or covering whilst at the centre.

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

I (the participant) confirm that I am not displaying any signs/symptoms of Covid-19 , have not tested positive for Covid-19 in the last 10 days and that I will follow safety guidelines of the activity centre during my visit.

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

Section 21 of the Firearms Act 1968 (Clay Pigeon Shooting only)

Section 21 of the firearms act 1968 states that a person who has been sentenced to imprisonment for a term of three months or more but less than three years or who has been sentenced to be detained for such a term in a detention centre or in a young offenders institution, shall not at any time before the expiration of the period five years from the day after his/her release have a firearm or ammunition in his/her possession. The same applies for anyone who has received a suspended sentence.

I (the participant) confirm that i have not been prohibited from possessing a firearm under section 21 of the Firearms Act 1968. I am aware that i will provided with ear & eye protection and will be required to wear them whilst in possession of a firearm.

Yes

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 do not have or have had any signs or symptoms of Covid-19 in the past 14 days and are fit and well to participate in your chosen activities. If you should have any queries, please give us a call on 01497 847897.

Adult Medical Form

Adult Medical & Disclaimer Form

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Organiser Details

Participant Details