Leader Medical & Disclaimer Form

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Organiser Details

School/Organisation:

Activity Date:

Participant 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 & Health Information

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All persons taking part in activities must complete the following fields as fully as possible prior to activity commencement. For your safety, please provide details of any condition that may affect your participation. All information given will be treated with the strictest confidence.

1. Medical Details

Do you have any medical conditions, or are you taking any medication or are you receiving any treatment that may affect your ability to participate in activities safely? *

Yes No

Do you have any allergies? (i.e. stings, bites, penicillin, elastoplasts etc) *

Yes No

Do you have any recurring or previous injuries (e.g., knee, ankle, shoulder, or back injuries) that could be aggravated by physical activity? *

Yes No

Some activities may not be suitable during pregnancy. Are you currently pregnant or think you might be pregnant? *
(We may advise seeking medical advice before participation depending on the activity.)

Yes No

Can you swim at least 25 metres unaided? *

Yes No

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

Yes No

Is there any other information that may be relevant to your safe participation that you have not already disclosed? *

Yes No

Please provide your approximate height, weight, and chest measurement.*
This information is required for equipment sizing and may be used where equipment must be prepared in advance for off-site activities (e.g. wetsuits & buoyancy aids)
(Please note: The maximum participant weight for all activities is 18 stone (114 kg).)

Emergency Contact Details

Emergency Contact Name:

Emergency Contact Number:

Doctors Name:

Surgery:

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

Disclaimer & Participation Declaration

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Outdoor adventure activities involve inherent and unavoidable risks, including the risk of physical injury, illness, damage to property, and in rare cases serious injury or death. These risks may arise from natural terrain, weather conditions, equipment use, physical exertion, or the actions of other participants.
Black Mountain Activities Ltd takes all reasonably practicable steps to provide a safe environment, qualified instructors, appropriate supervision, and properly maintained equipment. However, risks cannot be completely eliminated.

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.

By submitting this form and confirming below, I declare that:

I have read and understood the nature of the activity and the associated risks.
I acknowledge and accept that participation involves inherent risks and I voluntarily choose to take part.
I confirm that all information I have provided is true and accurate to the best of my knowledge.
I confirm that I am medically and physically fit to participate and that I have disclosed all relevant medical information that may affect my safety or the safety of others.
I agree to follow all safety instructions and comply with the directions of staff at all times.
I understand that failure to follow safety instructions may result in my removal from the activity where safety is compromised and that no refund may be given in such circumstances.
I understand that Black Mountain Activities Ltd will not be liable for any loss, damage or injury arising from risks inherent in the activity, except where such loss or injury results from negligence on the part of Black Mountain Activities Ltd.

Nothing in this declaration excludes or limits liability for death or personal injury resulting from negligence.

Digital Confirmation
I confirm that I have read, understood and agree to the above declaration and consent to participate in the activity under these terms.

Yes

Emergency Medical Consent
I consent to receiving emergency first aid and medical treatment from qualified first aiders or medical professionals if required during the activity.
I authorise Black Mountain Activities Ltd to arrange or obtain such emergency medical treatment on my behalf if necessary. I understand that I remain responsible for any associated medical or related costs.

Yes No

Photography Consent
I consent to Black Mountain Activities Ltd taking photographs and/or video footage of me during the activity and using these images for promotional and marketing purposes, including on the company website, social media platforms, printed materials and presentations.
I understand that I may withdraw this consent at any time by contacting Black Mountain Activities Ltd in writing.

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

Leader Medical & Disclaimer Form

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Organiser Details

Participant Details