11 Allen Road, London, N16 8SB Tel: 07711 031 318 Email: james@mountainwise.co.uk
Consent Form
 (must be completed in Block capitals & in ink)

First Name …………………………………………………………       Last name…………………………………

Address………………………………………………………………………………………………………………….

………………………………………………………………………………………        Post Code……………….

Phone……………………………………………………………           Mobile………………………………….…………..

Date of Birth…….. / …… / ……..                    Age……………..                                    

Male___  / Female ___   

 
Medical Information
Please give details of any medical conditions previous injuries or medication.
(Allergies/Epilepsy/Diabetes/Asthma etc)      Or any relevant information

……………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………
Emergency Contact:

Name…………………………………………………………………………………………………...…………………

Address…………………………………………………………………………………………………………………...

Relationship to participant   ...………………………………………………………………………………………….

Emergency contact numbers (24 hour)……………………………………………………………………………….

Declaration and consent
I understand that photographs, audio and video recordings of the participant engaged in Mountainwise activities may be used for promotional purposes and I hereby give my permission for this.
If you object, please tick this box ___

Should I / My child require emergency treatment an Mountainwise is unable to contact the named emergency contact person, I give permission for them to authorise the necessary emergency medical treatment including anaesthetic or blood transfusions, until the named person is contacted and arrives at the hospital. I understand the extent and limitations of the insurance cover provided.

I am the Parent / Guardian of the named child, give my consent for them to participate in the activities with Mountainwise (Over 18’s must sign for themselves).

Signature……………………………………………… 

Print Name.…………………………………………… 

Relationship to participant...…………………………

Date ……… /……… / …………

This form provides consent for all Mountainwise activities

rtn to home page