Student Medical & Disclaimer Form (Over 18's)

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Organiser Details

School/Organisation:

Activity Date:

Participant Details

Student 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

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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. Anyone under the age of 18 years MUST have a form completed by a parent/guardian.

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

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. wetsuit, buoyancy aid, please provide your approx. Height, Weight & Chest size.

2. Coronavirus (COVID-19)

We kindly ask that you take a lateral flow test prior to arriving for your activity. You should NOT attend or take part in any activity with Black Mountain Adventure if you display signs / symptoms of COVID-19, test 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 day of your 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

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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)-Please be aware that the government guidelines for Covid-19 differ between England and Wales. To ensure the safety of all visitors and Black Mountain staff, face masks/coverings are required (unless exempt) in any indoor area at Black Mountain Adventure and whilst travelling on the minibuses where transport is provided. Hand sanitiser is also provided and encouraged. Please take a lateral flow test prior to arriving at the activity centre or arriving at the meeting point of your activity. If your lateral flow test shows positive, please do NOT attend your activity and do seek a PCR test. For up to date Welsh Government Guidance, please visit www.gov.wales

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 & agree that I will not attend or take part in any activity if displaying signs/symptoms of Covid-19, have tested positive for Covid-19 by way of Lateral Flow Test or PCR test, or awaiting the results of a PCR test on the date of my organised activity.

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

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 and that you agree to not attend if you display any signs/symptoms of Covid-19, test positive for Covid-19 by way of Lateral Flow Test or PCR test, or are waiting the results of a PCR test on on the day of your activity. If you should have any queries, please give us a call on 01497 847897.

Student Medical Form (O18)

Student Medical & Disclaimer Form (Over 18's)

Page 1 / 3

Organiser Details

Participant Details