PLEASE USE A SEPARATE FORM FOR EACH PARTICIPANT (call for more copies)

Contacts: Adam Muirhead 07772 269761

Activity/Activities…………………………………………………Date(s)/Time……….…………………. Activity/Activities…………………………………………………Date(s)/Time……….…………………. Activity/Activities…………………………………………………Date(s)/Time……….…………………..

Participant’s First Name……………………………… Surname………………………………………………….

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

…………………………………………………………………………………………Post Code ………………………

Email (to keep you informed of future activities).........................................................................................................

Telephone numbers: Home ................................................................Mobile ................................................................................................

Date of birth ................................................................Age ................................Gender: Male / Female Delete as appropriate

Name of parent/guardian/next of kin...............................................................................................................

Address (if different from above) .................................................................................................................... .......................................................................................................................................................................

Emergency Contact Numbers Home (if different from above): ...................................................................

Work:................................................................................................Mobile: ................................................................................................

Do you have any disabilities, special needs and/or medical needs including allergies? Yes/No If ‘yes’, please state what they are:................................................................................................................ .......................................................................................................................................................................

Name of Doctor ................................................................Tel. No: ................................................................................................

Address ......................................................................................................................................................... .......................................................................................................................................................................

Behavioural Agreement

For under 18’s - Parent/Guardian please read and complete the following If 18 or over please read and complete yourself

I understand that my conduct/the conduct of my child whilst participating in the activity must be appropriate. Inappropriate behaviour, discrimination or bullying will not be condoned, nor tolerated. No alcohol/illegal drugs are to be consumed before/during the activity. Workers and community volunteers have the authority to refuse any person a place on activities if this should be deemed necessary.

Signature of parent/guardian/over 18:

................................................................................................

Please print name:

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Participants under 18 should also sign here:

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Please print name:

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(please tick)

• I give permission for my child named above to take part in the activity stated above □

• In the event of an emergency or accident I consent to my child receiving medical attention and First Aid treatment. □

• I give my permission for my child to be photographed during the activities for the purpose of publicity and promotion of further activities and nothing else. □

• *If attending Thorpe Park* I wish for my child to remain accompanied by workers whilst at the park □

Signature of parent/guardian/over 18:

................................................................................................

Please print name:

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Date: …………………………