Consent form

Participant information

Name of parent/guardian:

Names of child/children attending:

Ages:

Home address:

Postcode:

Contact telephone number:

Email address:

Medical information

Family doctor/surgery name:

Doctor's/surgery telephone number:

Do you or do any of your children suffer from any medical condition(s) or allergies or food intolerances that our session leaders should be aware of including any current medication?:

Please provide details of any medication that must be administered and in what situation?:

Emergency contact

Emergency contact name:

Emergency contact telephone number:

Relationship to children listed above:

Declaration of consent

I agree to the child/red listed taking part in outdoor activities during this session*:

I agree to Session staff taking photos of the child/ren listed above taking part in the l session and for these images to be used for promotional purposes on social media. NB: No child will ever be named alongside their image*:

I confirm, to the best of my knowledge, that the child/ren listed above do not suffer from any medical condition other than those stated above*:

I understand that outdoor activities are not free of risk and could result in injury. I understand that the Practitioners accepts no responsibility for loss, damage or injury caused by or during attendance of any outdoor activity except where such loss, damage or injury can be shown to result directly from the negligence of the Practitioners*:

I give permission for the staff to administer first aid if as and when the situation dictates*:

Keep in touch

I confirm that I would like my contact details to be added to the organisation’s database in order to receive details of future sessions and events by email and understand that I can unsubscribe at any time by emailing: [email protected]

Your Signature (required)

Print name:

Signature: - Mark your signature in the box below by clicking and dragging your finger/cursor: