Group Test – Birch Hall Adventures

Name of School or Group *

Date of Visit *

Date of visit or first day of visit (if multiple days)

Name of attendee *

First

Last

Date of Birth *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Medical Conditions *

Additional Information on Medical Conditions

Medication Taken

Allergies

Dietary Requirements (please include any religious requirements e.g halal)

Other information

NHS Number (if known)

Doctor's Name/ Surgery

Doctor's Telephone

Parent/ Guardian Details *

First

Last

Mobile Phone (should be contactable in an emergency) *

Email *

Communications consent (we do not share your data) *

I consent to receive communications from Birch Hall Adventures regarding events and activities at the centre
No communications please

Indicate preferred methods below: *

Photographs

I consent to pictures being taken for Birch Hall Adventures news and marketing purposes. Participants will not be named without further consent being obtained.

Consent Statement *

(To be completed by parent or guardian of participants under 18 years old) I am aware that the activities offered at Birch Hall Adventures are activities with a danger of personal injury or death. I have understood the nature of the activity and accept the risk involved. I confirm I am the parent/guardian of the above-named child and that I consent for him or her to take part in activities at Birch Hall Adventures. I consent to any emergency medical treatment necessary during the events including the administration of anaesthetics.
(To be completed by participants over 18 years old) I am aware that the activities offered at Birch Hall Adventures are activities with a danger of personal injury or death. I have understood the nature of the activity and accept the risk involved. I consent to any emergency medical treatment necessary during the events including the administration of anaesthetics.