Medical Declaration Form

Name (Required)

D.O.B (Required)

Address (Required)

Postcode (Required)

Email (Required)

Mobile Number (Required)

Telephone Number (Required)

Activity / Course (Required)

Activity Date/s (Required)

Emergency Contact (Required)

Please declare any medical / physical or mental conditions, illnesses or allergies from which you currently suffer. Please include relevant medication / treatment regime.
Also state specific concerns in your ability to cope with heights, exposure to cold, sun or water. (Required)

Outdoor activities are physical and demanding sports, with inherent risks and hazards associated with them. Whilst Active take all necessary steps to ensure the safety of all participants, unfortunately accidents do occur in consequence. Participants should consider risks and be aware of hazards. It is imperative that Active's staff instructions are followed.
Active accept no responsibility whatsoever for any loss or injury resulting from any persons' involvement in adventurous activities. It is understood and agreed that clients participate at their own risk.
By dating and competing the digital signature field below, I agree that I have read, understood and agree with the booking terms and conditions.
THIS INFORMATION WILL BE TREATED WITH THE STRICTEST OF CONFIDENCE

Digital Signature (Required)
Date (Required)