Booking, Medical and Consent Form

Booking Form
Course Title
Start Date

DayMonthYear
2 digit day, 2 digit month, 4 digit year
Finish Date

DayMonthYear
2 digit day, 2 digit month, 4 digit year
Name

First NameLast Name
Email
example@example.com
Birth Date

MonthDayYear
Gender
Phone number
MLT/AMI number
Address

Street Address

Street Address Line 2

CityCounty

Post CodeCountry
Emergency Contact
Name

First NameLast Name
Relationship to you
Phone Number
Email
example@example.com

Medical Declaration
Please List All Allergies (food, drugs, animals, insects. etc)
Please list any dietary requirements/preferences
Have you had, or are having any medical treatment that may either affect your ability to participate during this course or be compromised by your participation?
If yes please give details.
Are you currently suffering from an injury or condition, which may affect your full participation on the course?
If yes please give details.
All declared information is strictly confidential.

Informed consent
Outdoor activities such as climbing, hill walking, kayaking and mountaineering are activities with a danger of personal injury or death. Participants in these activities should be aware of and accept these risks and be responsible for their own actions.

Our activities are physically demanding. The days will be tailored as much as possible to suit your technical abilities and physical capabilities. However, for your own safety, we reserve the right to stop you participating at any point, for whatever reason.

Mountainous and water environments are subjected to the unpredictable and highly active forces of nature, conditions can change at any time. For safety reasons activities may have to be modified or cancelled at very short notice. This decision may be made at any point during the course, but when at all possible, an alternative will be offered.

In signing this form you are accepting that there is risk of accidents and injury in the activities you will be undertaking.
Signed
Please type name above
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit year
Are you happy for Far Out Pursuits' staff to take and share photos?
Please demonstrate you are a human!
Should be Empty: