Outdoor Registration Form

Outdoor Medical Form

It is important that we know about special requirements for participants in our events. Anyone attending a Rockburn Ltd outdoor course (participating or spectating) should complete this form and 'Submit' before you arrive. Alternatively, this can be printed from the Outdoor Events page on our website at http://rockburn-bridport.com/outdoor/ and brought with you to the event.
Which event is the group participating in? *
Rock-taster/Intro to Outdoor/Other
Event Date *

Day Month Year
Participant Information:

Please provide information of medical conditions/illnesses/ allergic reactions that participants have (e.g. food allergy, heart conditions, pregnancy, back problems) and any medication that is used to control these conditions (e.g. inhaler, Adrenalin etc.):

If there is an existing medical condition, we recommend advice is sought from a GP to establish the suitability of the activity.

First Name

Surname

D.O.B.

Relevant Medical Information

Main Participant

Participant 2

Participant 3

Participant 4

Participant 5

Participant 6

Main/Booking Participant's Address *

E-mail: *
Info regarding the event will be sent here
Emergency Contact Information:
Emergency Contact Name *

First Name Last Name
Emergency Contact Number *

Area Code Phone Number
Relationship to Participant *
Declaration:
I confirm that: *

I have read and understood this form and declared all existing medical conditions. I will not take part in any activity that I know may aggravate an existing medical condition. I agree to take responsibility for my personal belongings at the Climbing Session. I agree to be a responsible participant during the Climbing Session and follow theInstructor’s directions.
Signature of Responsible Person/Participant (18+) *

Clear
Print/Type Name *

First Name Last Name
Date of Completion *

Day Month Year
Date
Should be Empty:

Outdoor Medical Form