Joining Form / Acknowledgement of Risk
Your Details
Surname……………………………………………………………….
First Name…………………………………………………………….
Title …………………………………………………………………...
Age……………………………………………………………………
Date of Birth …………………………………………………………
Contact details (email address) ………………………………………
First Aid Training – please provide details …………………………..
………………………………………………………………………..
Emergency Contact
Name ………………………………………………………………….
Number………………………………………………………………..
Acknowledgement of Risk
High ropes course activity is inherently dangerous.
During the training and assessment you will be expected to operate as a team and at times without direct supervision.
All training will be conducted to the best safety practice and all risks will be assessed, you will however be exposed to the risks associated with the activity.
By signing and attending you accept responsibility for your actions and the dangers of the event.
Signed ………………………………………………………
Date………………………………………………………….
Date Course Starts:…………………………………………..
MEDICAL INFORMATION
All information received is confidential. Please circle YES or NO to all of the following:
Have you ever had or currently have......
Asthma, wheezing with breathing or wheezing with exercise? Yes / No
Claustrophobia or agoraphobia (fear of closed or open spaces)? Yes / No
Emotional or behavioral health problems? Yes / No
Epilepsy, seizures, convulsions or taken medication to prevent them? Yes / No
Recurring migraine headaches or take medication to prevent them? Yes / No
History of recurrent back problems or surgery? Yes / No
History of diabetes? Yes / No
Any arm or leg Problems? Yes / No
Inability to perform moderate exercise (walk a 15 minute mile)? Yes / No
History of heart attacks? Yes / No
Problems with balance or recurring dizziness? Yes / No
Any type of hernia? Yes / No
Impairment of sight, hearing or speech? Yes / No
Do you regularly take prescription or non- prescription medications?
(Excluding birth control) Yes / No
Are there any other medical conditions that you think we should be aware about? Yes / No
Women: Could you be pregnant? Yes/ No
The information I have provided about my medical history is accurate to the best of my knowledge.
Sign……………………………. Print Name……..……………………
Date……………………………
Tree Top Adventure, Llanrwst Rd, Betws-y-Coed, LL24 0HA
01690 710914 – www.ttadventure.co.uk