Residential Activity Camp Consent Form

Please take some time to accurately fill out this form before your activity.

One form must be completed for every individual taking part.

Participant:

First name

Last name

Birth Date

Address

Phone

Please detail any medical details and/or injuries:

Please detail any allergies or dietary information so that we can best cater for your child's needs.

Child's Educational/Additional Needs/Special Educational Needs

Tick all that apply:

My child does not speak fluent English.

My child can not understand and follow instructions that have been said in English.

My child will need support with day to day activities (e.g. going to the toilet or eating)

Swimming Ability:

My child can confidently swim more than 50m.

My child can confidently swim more than 25m.

My child can swim up to 25m.

My child cannot swim.

Emergency Contact:

Please update is if any of the below details change.

Emergency Contact one: Full Name

Emergency Contact one: Relation to child

Emergency Contact one: Phone

Emergency Contact two: Full name:

Emergency Contact two: Relation to child

Emergency Contact two: Phone

Drop off / collection

Please list the full name of those authorised to collect your child from camp

Disclaimer:

Statement of Risk

GoSport Activity Centre places safety as a priority. Adventurous Activities involve some risk for the people taking part. GoSport Activity Centre and its coaches aim to keep these risks as low as possible. The chances of serous injury are extremely low, but the chance of minor Injuries (bruises. bumps and less likely injuries such as minor fracture) are a possible result of taking part in Adventurous Activities. GoSport and its staff will minimise the actual dangers by:

Carrying out a careful risk assessment of risks before commencing the activity.
Only using experienced instructors with the appropriate qualifications for the activity.
Giving clear safety instructions to everyone participating.
Ensuring equipment and clothing are well-maintained and are suitable for the activity and environment
Ensuring activities are within the capabilities of the participants.
Asking participants to supply any medical conditions or information to allow reasonable adjustment.
Ensuring good hygiene standards are kept.

We expect participants to co-operate with GoSport and its staff, to ensure the safety of all participants, by following instructions and through the answering of Personal Information Forms honestly especially when providing information relating to health and safety.

Media Permission Statement: By ticking the box below I give permission for my child to be photographed and videoed during the activities. Media taken may be used by GoSport Activity Centre or in conjunction with GoSport Activity Centre.

Yes, I give permission to the media statement above and give photo and video permission.

Yes, I confirm that the participant is fit, healthy and able to partake in adventurous activities at GoSport.

Yes, I confirm that I will inform GoSport if any of the information given in this form changes.

Yes, I agree to all the contents of this form on behalf of the participant.

Signature (Under 18s require parent/guardian signature)

Yes, I want to receive emails from GoSport Activity Centre.

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Residential Activity Camp Consent Form

Participant:

Emergency Contact:

Drop off / collection

Disclaimer:

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