PARTICIPANTS PERSONAL
DETAILS REQUEST FORM
Please give details in all relevant sections of this form. Failure to do so could result in delay of actions due to lack of information.
ACTIVITY (Please circle)
Kayaking, Canoeing, Teambuilding, Orienteering, Raftbuilding, Ropes Course, Sailing, Windsurfing, Other ______
DATE OF ACTIVITY______*SCHOOL/CLUB/PRIVATE
NAME ______D.O.B ______
ADDRESS ______
______
TEL NO ______EMAIL ______
CAN YOU SWIM * Yes / No HOW FAR * 25m/50m/100m/ Other______
MEDICAL INFORMATION
Do you have any medical details we should be aware of, i.e. asthma, epilepsy?
______
______
Do you have any special needs or disabilities? *yes/no
If yes, please state______
Do you require medication while on activity? *yes/no
If yes, please state ______
INSTRUCTORS CAN CARRY MEDICATION UNDER CERTAIN CIRCUMSTANCES.
NEXT OF KIN (1ST CONTACT)
NAME:______
ADDRESS:______
______
TEL NO: ______
RELATIONSHIP:______
NEXT OF KIN (2nd CONTACT)
NAME:______
ADDRESS:______
______
TEL NO: ______
RELATIONSHIP:______
Participants aged 16 and under:
Participants aged 16 and under require a signature from a *Parent / Guardian before they can continue with activities. Guardian must be aged 18 years or over.
I ______give permission for ______
to participate in ______at Creggan Country Park.
*Parent/Guardian signature______
*Participants Signature______ Date ______
Instructors Signature ______ Date______
*Delete as appropriate.
IMPORTANT NOTES ON YOUR VISIT:
In relation to the Health and Safety of participants and staff, personal and medical information will only be made available to members of Creggan Country Park staff if deemed necessary. You will be made aware of this routine policy if it affects you in any way. If you would like to discuss this please feel free to talk to your instructor.
You must bring these items with you for your visit:
a. Change of clothes
b. Old Pair of trainers to go into water with.
c. Towel and toiletries for shower
d. Swimming gear for under wetsuit.
e. Sunscreen (even in poor weather).
Please arrive at least 10 minutes before the time you have booked to allow for changing time.
Creggan Country Park is a neutral environment and with this in mind we ask that all visitors refrain from wearing football jerseys.
Creggan Country Park is constantly trying to attract visitors and occasionally uses photographs of groups visiting the centre in our promotional material. If you are the parent/guardian of a participant OR a participant yourself, please tick the relevant box below:
I am willing to allow my photograph to be used in promotional material for Creggan Country Park.
Signature: ______
*Participant / Parent Guardian
Date: ______
I do not wish my photograph to be used in promotional material for Creggan Country Park.
Signature: ______
*Participant / Parent Guardian
Date: ______
Telephone number: 028 71 363 133 Fax number: 028 71 363 135
Email:
Website: www.creggancountrypark.com