Child Medical & Disclaimer Form

Page 1 / 3

Organiser Details

Group Organiser:

Name of person who has made the booking

Activity Date:

Participant Details

Child's Name:

Date of Birth:

Address:

Parent / Guardian Telephone Number:

Gender of child:

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

Medical Information

Page 2 / 3

All child under the age of 18 years taking part in outdoor activities must have this form completed as fully as possible by a parent or guardian, prior to commencement of the chosen activity/ies. All information given will be treated with the strictest confidence.

1. General Medical Details

Does your child have any medical conditions?

Yes No

Is your child receiving any medication or treatment?

Yes No

Does your child suffer from allergies? i.e. stings, bites, penicillin, elastoplasts etc

Yes No

Is your child prone to repetitive sports injuries?

Yes No

Can your child swim?

Yes No

Does your 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. wetsuit, buoyancy aid, please provide your child's approx. Height, Weight & Chest Size.

2. Coronavirus (COVID-19)

Your child must NOT attend or take part in any activity if they are displaying signs / symptoms of Covid-19, tested positive for Covid-19 by way of a lateral flow test or PCR test, or are awaiting the results of a PCR test on the date of their activity.

Yes

Please tick to acknowledge you have read & understand

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

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.

Coronavirus (Covid-19)-Please be aware that government guidelines differ between England and Wales. To ensure the safety of your child and all accompanying children, adults and the staff of Black Mountain Adventure, please visit the Welsh Government website www.gov.wales for the latest guidelines and information on face masks/coverings (unless exempt), Lateral flows tests and PCR test etc, prior to your activity and visit to Black Mountain Adventure.

Understanding & Acceptance of Risk

I (the parent/guardian) can confirm that all details given are true and correct and that my child is fit and able to participate in the activities organised.

Yes

I (the parent/guardian) understand that all activities take place in the outdoors where conditions may be wet, slippery and hazardous. I accept that there is an element in unforeseen risk and give consent for my child to take part in the organised activities.

Yes

I (the parent/guardian) agree to ensure that my child understands, as far as reasonably possible, that is is important for his/her safety, that of their peers and as a whole, any rules and instructions given by staff are strictly adhered to at all times. I understand & agree that should an instructor feel my child is jeopardizing the safety of themselves, and/or others, they will be excluded from the activity without refund.

Yes

I (the parent/guardian) confirm & agree that my child will not attend or take part in any activity if they are displaying signs/symptoms of Covid-19, test positive for Covid-19 by way of lateral flow test or PCR test, or are awaiting results of a PCR test on the date of their organised activity.

Yes

Consent

I (the parent/guardian) consent to any emergency medical treatment necessary to be given to my child by on-site first aiders or qualified medical respondents in the event of an accident.

Yes

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

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 on behalf of your child that they are fit and well to participate in activities and that they will not attend or take part in any activity if showing signs/symptoms of Covid-19, test positive for Covid-19 or are awaiting the results of a PCR test on the date of their activity. If you should have any queries, please give us a call on 01497 847897.

Child Medical Form

Child Medical & Disclaimer Form

Page 1 / 3

Organiser Details

Participant Details