Group Test

Name of School or Group *

Date of Visit *

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

Name of child *

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

Please include below details of any medicines being taken, any allergies e.g. penicillin, plasters etc. or special dietary or other treatment necessary

Medication Taken

Allergies

Dietary Requirements

Other treatments

NHS Number (if known)

Doctor's Name/ Surgery

Doctor's Telephone

Any Religious Needs

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: *

Telephone
Post
Email

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.