NOTE: How Stean Gorge does not accept paper waivers, please submit electronically.

This form must be completed for each person attending an outdoor activity course and signed by you the legal guardian for those under 18. The information given is confidential and is only available to staff who need to know for safety reasons. They are kept securely after each course. Please be aware that you must be free from impeding effects of medication, substances or alcohol.

This first section is to be completed by the parent or guardian. Please enter your legal name as it appears on your passport.

Full Name

Date of Birth

Address

First Line and Post code will suffice.

Emergency Phone number

Who to contact in case of emergency

Our first point of contact will be through the leaders of the group.

IMPORTANT

The activities we provide are physical and demanding, which obviously have inherent hazards, associated with them. Whilst How Stean Gorge will take all necessary precautions to try and ensure the safety of all participants, unfortunately accidents can occur. How Stean Gorge accepts no responsibility whatsoever for any loss or injury resulting from any persons’ involvement in these related activities, unless to be proven by our negligence. It is understood and agreed that individuals participate at their own risk. How Stean reserves the right to cease the activity if instructor judges the actions or ability of the participant is not of the expected standard. Nothing in this Medical and consent form excludes or limits How Stean Gorge’s legal obligations in relation to the health and safety of all participants. I have read and understand the above statement.

Click to Sign

Signature

Electronic Signature Consent

By checking here, you acknowledge you have read and understand the above terms, and are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.

Please select how many of your children are participating:

First Minor Name

Childs Name

First Minor Date of Birth

First Details of any medical conditions that may affect the course member’s ability, including advice given by the doctor.

Type Nil if none

First

First Please indicate if the course member will be taking any medication during the activity and who is responsible for it. Type Nil if none.

PLEASE NOTE: Staff are not allowed to administer any medicines whatsoever and do not have medications available such as insect creams or aspirin. However, instructors are trained in first aid, carry first aid kits and will look after medications for those under 18 (e.g. inhalers) if written evidence is given that the medication is required.

First Can your child swim 25 meters?

Can your minor swim ? Yes or No

Second Minor Name

Childs Name

Second Minor Date of Birth

Second Details of any medical conditions that may affect the course member’s ability, including advice given by the doctor.

Type Nil if none

Second

Second Please indicate if the course member will be taking any medication during the activity and who is responsible for it. Type Nil if none.

Second Can your child swim 25 meters?

Can your minor swim ? Yes or No

Third Minor Name

Childs Name

Third Minor Date of Birth

Third Details of any medical conditions that may affect the course member’s ability, including advice given by the doctor.

Type Nil if none

Third

Third Please indicate if the course member will be taking any medication during the activity and who is responsible for it. Type Nil if none.

Third Can your child swim 25 meters?

Can your minor swim ? Yes or No

Fourth Minor Name

Childs Name

Fourth Minor Date of Birth

Fourth Details of any medical conditions that may affect the course member’s ability, including advice given by the doctor.

Type Nil if none

Fourth

Fourth Please indicate if the course member will be taking any medication during the activity and who is responsible for it. Type Nil if none.

Fourth Can your child swim 25 meters?

Can your minor swim ? Yes or No

Fifth Minor Name

Childs Name

Fifth Minor Date of Birth

Fifth Details of any medical conditions that may affect the course member’s ability, including advice given by the doctor.

Type Nil if none

Fifth

Fifth Please indicate if the course member will be taking any medication during the activity and who is responsible for it. Type Nil if none.

Fifth Can your child swim 25 meters?

Can your minor swim ? Yes or No

Sixth Minor Name

Childs Name

Sixth Minor Date of Birth

Sixth Details of any medical conditions that may affect the course member’s ability, including advice given by the doctor.

Type Nil if none

Sixth

Sixth Please indicate if the course member will be taking any medication during the activity and who is responsible for it. Type Nil if none.

Sixth Can your child swim 25 meters?

Can your minor swim ? Yes or No

NOTE: How Stean Gorge does not accept paper waivers, please submit electronically.

Youth Groups Consent with Swim