Page 1
Page 2
Page 3

Company

Adult Medical & Disclaimer Form

Page 1 / 3

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 *

Email:

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?

Do you have a medical condition?

Yes No

If yes, please give details about condition

Are you receiving any medication or treatment?

Are you receiving any medication?

Yes No

If yes, please give details about medication

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

Do you have any allergies?

Yes No

If yes, please give details about allergies

Are you prone to repetitive sports injuries?

Yes No

If yes, please give details about injury

Can you swim? (if no please state if water confident)

Are you a non-swimmer?

Yes No

If no, please state if confident in water

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

Do you have any dietary need?

Yes No

If yes, please give details about dietary needs

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

Any additional info that may be relevant?

Yes No

If yes, please give details

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

Height (cms)

Weight (kilos)

Chest (cms)

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.

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.

I (the participant) can confirm that the details given are true & correct:

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.

I (the participant) accept that there is an element of risk in the activities i am undertaking:

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

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 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

Medical Information

Page 2 / 3

1. General Medical Details

Emergency Contact Details