How Did You Hear About the Abseil Event? ______

How Did You Hear About the Abseil Event? ______

REGISTRATION FORM

Please complete all sections of this form and return it to: Joanne Dobbie, Centre Fundraising Manager, Maggie’s Merseyside at Clatterbridge, Bebington, Wirral, CH63 4JY

Before completing this form please read carefully the Conditions of Entry which are listed below. Please write clearly and complete all the sections listed.

CHARITY

I will be raising money for …………......

HOW DID YOU HEAR ABOUT THE ABSEIL EVENT?______

PERSONAL DETAILS (please use capital letters)

Title______Forenames______

Surname______Address______

______Postcode______

Home phone ______Mobile______

Email______Date of Birth______(You must be at least 18 years of age to take part)

The abseil event is scheduled for 8thAugusthowever the abseil cannot take place during extreme weather conditions and will be rescheduled to 15th August 2015if necessary. Please tick the box to confirm that you are available for allthe dates, as it will not be possible to refund money if you can not make the alternative date.

□I confirm that I am available on the 8th August 2015 & 15th August 2015.

There will be two working abseil ropes so friends or partners can abseil at the same time, if you would like to abseil with someone please list their name below. (Please note we cannot guarantee your request, but will try our best.)

□ Solo abseil □Partner Abseil: Name of Partner: ______

MEDICAL DETAILS

Please indicate below if you have any pre-existing medical conditions or are on any medication. We may ask you to provide a doctors note confirming you are fit enough to take part if necessary. Please note in addition to the 150ft free fall abseil participants will have to climb approximately 50 or 224 steps (if the lift is unavailable) up to the top of the tower to access the abseil platform.

Pre-existing medical conditions(include details about asthma, diabetes, epilepsy etc.) ______

Details of any hospital treatment in the last 12 months______

Medication Taken______

Are you allergic to anything? (E.g. penicillin, plasters etc.)______

NEXT OF KIN DETAILS

Name (in full) ______Relationship______

Home Phone ______Mobile______

CONDITIONS OF ENTRY

In order to participate in the abseil event you must read and agree to the following terms and conditions and sign the declaration at the bottom of the form.

I agree that:

  • I am over 18 years of age.
  • I am in a good state of medical and fitness health and have declared any medical conditions on this form and I take full responsibility for my own fitness to take part.
  • I am able to participate on the 8th August2015and the backup date of 15th August 2015 I am aware that abseiling is an activity with a danger of personal injury or death; and accept these risks and responsibility for my own actions and involvement.
  • In the event of illness or an accident at the event I hereby give my permission for Liverpool Cathedral or Awesome Walls Climbing Centre first aidersto initiate medical treatment and notify my next of kin in case of hospitalisation.
  • I agree to abide by the rules and instructions given by the abseiling instructors to me on the day of the event.
  • I understand that any participant who has been drinking alcohol, taken drugs or behaves irresponsibly; in such a way to risk his/her safety or that of other participants or the instructors will not be allowed to participate in the abseil event and may be asked to leave the Cathedral site.
  • I understand that Liverpool Cathedral is a Grade 1 listed building and a place of worship and agree to respect the building and will not cause any damage to the fabric of the building.
  • I confirm that the above information is correct and if any information changes I will inform Liverpool Cathedral.

I apply to take part in the Liverpool Cathedral Charity Abseil, and abide by the Conditions of Entry listed above

Signature Name (capital letters) Date

______

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