Consent, Medical and Emergency Contact Form

Course, Event or Expedition *

The Course, Event or Expedition that Consent, Medical and Emergency Contact information is being provided

Name of participant *

First

Last

Email *

Participant Date of Birth *

Participants phone number

Name of participants legal guardian if under 18 or requires guardian consent

First

Last

Phone Number 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 authorise the Happy Explorer 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 activity
I understand that if the participant is physically unfit or unable to participate on a course, event or expedition, that they may have to be withdrawn by the leader at any time in the run-up to, or during the activity.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 can be physically demanding and that I may sometimes need to carry my own provisions.
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 Happy Explorer has Public Liability Insurance and that I can request a copy of this from Happy Explorer. 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 video and photographs taken whilst involved in the event/activity, to be used for display or publicity purposes and may also be used on the Happy Explorer 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 Conditions
Asthma
Epilepsy
Arthritis
Diabetes
Hay fever
Skin Conditions
Food Allergies
Food intolerance
Allergies (other)
Haemophilia
Migraine
Other

PLEASE 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 Name *

First

Last

Emergency Contact relationship to Participant *

Emergency Contact Phone Number *

Any other information you would like us to know

Email *

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