Adult Consent Form

Name *

First

Last

Email *

Phone

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Date of birth

Type of visit

Group
Party

Date and time of visit

Date

Time

Emergency contact name

Relationship to emergency contact

Emergency contact number – mobile

Emergency contact – home/work

Emergency contact email

Medical information

Do you suffer from any medical, physical, emotional or behavioural conditions? (For example: asthma, vertigo, heart condition, ADHD, etc.) YES or NO

If yes, please specify

Are you currently undergoing any form of medical or psychological treatment including any medication? YES or NO

If yes, please specify

Do you have any allergies? YES or NO

If yes, please specify

Please provide your doctor's name and address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Photography consent

Photographs and videos may be taken of the participants on any activity session during your visit to Blaithwaite House. This material may be displayed on the website and in promotional documents and advertisements for the centre. Please confirm your acceptance below.

I agree to my photograph being used by Blaithwaite Estate for marketing purposes, either online or in print.
I don’t want my photograph to be used by Blaithwaite Estate

Statement

I agree to participate in the activities delivered by Blaithwaite Limited and understand that all activities carry a degree of risk. I undertake to inform the centre on the day, in the event of any changes in my health and fitness prior to the proposed visit. I understand that it is extremely important for my safety and the safety of the group that any rules and instructions given by the staff in charge are obeyed at all times. I agree to members of staff giving permission for me to receive any medical treatment in an emergency where I cannot do so myself. I confirm to the best of my knowledge that the above information is correct and that I have read and understood the information contained therein.

Date completed