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Contact
Individual Consent Form
Attending an Activity With Us?
Please complete the consent form, and ensure you have the contact details of a parent/guardian person if you are under 18. This form will request consent from the adult, by asking them to click a link in an email verifying consent to attend.
Event Name
*
Select Event
Gold DofE Residential - 15/4/19 - DOE19-MA1
Gold DofE Residential - 29/7/19 - DOE19-MA&C2
Gold DofE Residential - 5/8/19 - DOE19-MA&CK3
Gold DofE Residential - 19/8/19 - DOE19-MA&CK4
Putney High Practice - 28/5/19 - PUT19-GP1
Putney High Assessed - 28/8/19 - PUT19-GA1
Event not listed -
Please select your event. If your course / event is not in the dropdown list then please select 'Event not listed'. After selection You will then be able to enter the start date and event name.
Event or course name / description
*
eg. Gold DofE canoe expedition (River Severn) or Gorge Walking Day (Melton Scouts)
Event / Course start date
*
Course code (if known)
This information can be found on the information pack sent to your or your group leader. If you do not have this information then you will still be able to submit the form. eg. DOE17-Y81
Personal Details
Attendee Full Name
*
Attendee Date of Birth
*
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Attendee Email Address
*
Attendee Mobile No on the day
*
Contact Address
*
Has your home address changed since you made your booking?
NO
YES
Address
Post Code
Emergency contact information during course
Emergency Contact Name
*
Emergency Contact Address
*
Emergency Phone
*
Do you wish to add a second contact?
YES
NO
Emergency Contact Name 2
Emergency Phone 2
Use Different Address
Emergency Contact Address 2
Medical History
Please provide details of any medical conditions, allergies, medication being taken, disabilities or injuries (present and past)
Have you ever experienced or suffered from:
Joint / Muscle pain
Provide more details
Broken bones
Provide more details
Back problems
Provide more details
Do you suffer from:
Asthma
Provide more details
Diabetes
Provide more details
Epilepsy
Provide more details
Hay fever
Provide more details
Allergies
Provide more details
Heart conditions
Provide more details
Have you had a Tetanus injection:
*
Yes
No
Don't know
Other relevant medical information?
Yes
No
Dietary Needs
Please provide details of any Dietary requirements or allergies.
Do you have any allergies
Nuts
Provide more details
Shellfish
Provide more details
Other
Other Allergies
add one per line
Provide more details
Are you intolerant to any foods?
Milk (Lactose)
Provide more details
Wheat (Gluten)
Provide more details
Other
Other Intollerances
add one per line
Provide more details
Want to provide other dietary information?
Yes
No
Swimming Capability
Water Confidence:
*
Confident Swimmer- able to swim 100m+
Basic Swimmer - Can swim a pool length (25m) with ease and unassisted
Non Swimmer - or can only swim a pool width or less, or requires assistance
Arrival method
Arrival Information
*
Not decided yet
Arriving at meeting point by car
Arriving by train
Station
Time
:
HH
MM
AM
PM
Equipment loan
Do you need us to supply any of the following item : please note that lost or damaged items must be paid for.
DofE Canoeing Expedition
Please note that Canoes, paddles, boyancy aids, waterproof barells, trangia stoves and tents are supplied as standard.
Sleeping bag
Foam Sleeping mat
Compass
survival bag
Please supply me 1x Gas cartridge cost £6 (payable on the day).
DofE Walking expedition
Please note that trangia stoves and tents are supplied as standard.
Rucksack
Foam sleeping mat
sleeping bag
survival bag
compass
Please supply me 1x Gas cartridge cost £6 (payable on the day).
Consent
Thank you for completing the medical and consent form. This form now requires an electronic signature. If you are under 18 then this form must be signed by a parent or guardian, if you are over 18 then please enter your own details. Please enter the name and email address of the person signing the form in the space below. They (or you) will then receive a copy of this form to your email address, which can be reviewed and submitted using a simple one click process.
Email for Consent
*
address to whom consent form will be sent for confirmation (Parent/Guardian if under 18)
Name of person signing / authorising this form
*
Relationship to you
*
parent
legal guardian
myself (I am over 18)
Confirm you are human
Phone
This field is for validation purposes and should be left unchanged.