Consent, Medical and Emergency Contact Form Please enable JavaScript in your browser to complete this form.Course, Event or Expedition *The Course, Event or Expedition that Consent, Medical and Emergency Contact information is being provided Name of participant *FirstLastParticipant Date of Birth *Participants phone number if over 18 Participants Email if over 18 EmailConfirm EmailThis email address must contain the name of the participant for identity confirmationName of participants legal guardian if under 18 or requires guardian consentFirstLastEmail address of Name of participants legal guardian aboveEmailConfirm EmailThis email address must contain the name of the participant legal guardian for identity confirmationPhone Number Name of participants legal guardian Consent and understanding I acknowledge receipt of and understand the information regarding the proposed course, event or expedition and consent to the above-named participant taking part. I will inform the WithDave Ltd in writing of any changes in the health of the participant/my health prior to the date of departure. I authorise the WithDave Ltd instructor to take emergency decisions on my behalf, including the giving of permission for medical treatment on the advice of the medical authorities present having taken the following medical information into account. I agree to inform you in writing as soon as possible of any change in the medical circumstances between the date signed and the start of any activityI understand that if the participant is physically unfit to participate on a course, event or expedition, that they may be withdrawn by the Instructor, leader or Supervisor at any time in the run-up to, or during the activity. I understand that the participants may need to make changes to their lifestyle to prepare for a physically demanding activity and that they are responsible for their fitness whilst on an activity. I understand that participation in this activity will be physically demanding and that I may need to carry my own provisions for the entire activity I understand that outdoor activities such as this activity can carry a risk of personal injury and in extreme cases, the possibility of fatality. I understand that WithDave Ltd has Public Liability Insurance and that I can request a copy of this from WithDave. No insurance is offered for the loss or damage to personal property during the activity. I acknowledge the need for self-discipline and responsible behaviour whilst participating in any activity. I understand that participants may not be supervised by an adult at all times. I have ensured that he/she/I understands that it is important for his/her/my safety and for the safety of the group for him/her/me to behave in a reasonable manner and that any reasonable rules and instructions given by staff will be followed.I give my permission for any photographs taken whilst involved in the event/activity, to be used for display or publicity purposes and may also be used on the WithDave promotional material. I understand that in the event of the participant not completing the activity the full cost is still due and is non-refundable. Medical - Do you, or have you ever suffered from any of the following? Heart ConditionsAsthmaEpilepsyArthritisDiabetesHay feverSkin ConditionsFood AllergiesFood intolerance Allergies (other) HaemophiliaMigraineOtherPLEASE BE HONEST WITH YOUR ANSWERS TO HELP US, SHOULD AN EMERGENCY ARISE (All information provided will be treated with the strictest of confidence.)If you have ticked any of the above or have any other medical condition which is not mentioned please specify below:If you are on any medication or carry any medical aids i.e. Inhaler, EpiPen, Medical Warning Card etc. Please specify below:Do you have any dietary needs i.e. vegetarian, gluten free etc.? Or food dislikes Emergency Contact 1 Name *FirstLastDuring Course, Event or Expedition Emergency Contact 1Can be contacted by phoneCan be contacted by emailCan not be contacted Can this person be contacted by phone or email in an emergency Emergency Contact 1 Address *Emergency Contact 1 Address during Course, Event or ExpeditionEmergency Contact 1 Post Code *The Post Code of Emergency Contact 1 during Course, Event or ExpeditionEmergency Contact 1 relationship to Participant *What is the relationship of Emergency Contact 1 relationship to the ParticipantDaytime phone Number for Emergency Contact 1 *A phone number where the emergency contact can be contacted during the normal work hoursNight time phone Number for Emergency Contact 1 *A phone number where the emergency contact can be contacted during the nightMobile phone Number for Emergency Contact 1 *Mobile phone number for emergency contact 1Emergency Contact 2 Name *FirstLastDuring Course, Event or Expedition Emergency Contact 2 Can be contacted by phoneCan be contacted by emailCan not be contacted Can this person be contacted by phone or email in an emergency Emergency Contact 2 Address *Emergency Contact 2 Address during Course, Event or ExpeditionEmergency Contact 2 Post Code *The Post Code of Emergency Contact 2 during Course, Event or ExpeditionEmergency Contact 2 relationship to Participant *What is the relationship of Emergency Contact 2 relationship to the ParticipantDaytime phone Number for Emergency Contact 2 *A phone number where the emergency contact can be contacted during the normal work hoursNight time phone Number for Emergency Contact 2 *A phone number where the emergency contact 2 can be contacted during the nightMobile phone Number for Emergency Contact 2 *Mobile phone number for emergency contact 2Any other information we need to know or information you would like us to know For example: Any long term medical, health or wellbeing issues. Any recent medical, health or wellbeing issues or treatments etc CommentSubmit
