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Hednesford’s “It’s A Knockout”Team Application Form

On Saturday 17th August 2013, The Friends of Hednesford Park are again hosting the popular “It’s A Knockout” event in the park. This fun and action packed competition will be co-ordinated by specialist staff from Simply The Best Entertainments. They are a professional company with all the appropriate health and safety measures in place to make sure the day is fun and safe for all to enjoy.

Please enter your details below to register your team for this event.On receipt of this form we will contact you to confirm your place has been reserved.A donation per team is required for all businesses, voluntary groups are free. Please make cheques payable to “The Friends of Hednesford Park” and include an SAE if you require a receipt.

Name of Team
Team Leader Contact Details
Name:
Telephone:
Address:
Email:
Number (up to 6 per team) and age of people involved in the team. If team members are under 18 then please make sure the parental consent form (page 3) is signed
Names of team members
Please provide a brief description of your team (This information will go on our website and programme at the event) If you wish to provide photographs of your team then please e-mail to

On the day, we will have a photographer taking photos/videos of the event to use on our website and also any press or media release as we deem necessary.

Please tick this box if you DO NOT wish to have your photo taken or used for any publicity purposes

All personal information will be held in accordance with The Information Act 1998

First Aid will be in attendance at the event, your information will enable the emergency services to act quickly and to the patients best interest if you provide the information requested.

Medical details of any team members that may need appropriate medical support

Name of team:
Name of team member with medical condition:
Contact Details:
Age:
Contact Details of Doctor:
Medical Condition:
Medication Details:
Allergy Details:
Emergency Contact Details:
Emergency Contact’s relationship to team member:
Any other information relevant that would help the paramedics if they had to attend:

Please copy page 2 for two or more team members with medical conditions

Registration Form for Under 18’s

Child’s Name:______M / F:______

Age:______

Address:______

______Postcode:______

Home Telephone Number:______

Emergency Contact Name 1 / Relationship / Telephone Number
Emergency Contact Name 2 / Relationship / Telephone Number
  • Please fill in page 2 if your child has any illness or medical condition. Please also indicate if your child is taking any medication, with details and dosage.
  • I, as parent/guardian am aware that this event involves physical activity and to the best of my knowledge any medical condition stated will not put them or anyone else at risk and that there is no reason why my child should not participate in physical activities.
  • I confirm that my son/daughter does not suffer from any medical conditions other than those stated.
  • I consent to my son/daughter to receiving medical treatment which a qualified medical practitioner may see necessary.
  • My child is over the age of 5 years old.

PARENT/GUARDIAN SIGNATURE______DATE______

07896 239717