Participant Medical Form

Please fill out one form PER participant

We will keep this completed form for one year please ensure you keep us up to date of any changes.

Participants First name*

Participants Last name*

Date of Birth*

Day

Month

Year

School attended

Address*

Participant preferred name

Ethnicity*

Gender*

Male

Female

Allergies or dietary requirements*

YES

Allergies or dietary requirements description

Additional needs*

YES

Additional need description

Photo consent*

YES

External photo consent*

YES

For media use etc outside of our charity. Local newspapers etc.

First aid consent*

YES

Pick up pin/ safe word (for under18s)

Parent Carer full name /emergency contact 1*

Phone number*

Email*

Second emergency contact full name *

Phone number*

I agree to keep adventure dolphin up to date should any of these details change

I agree

I have read the Adventure Dolphin club statement:*

I agree

1. I have ensured that I/the participant understand(s) the nature and risks of the activity and for his/her/my safety and for the safety of the group that any rules and instructions given by leaders are followed.

2. I undertake to inform the leader of the activity of any changes in the fitness or health of the participant/myself prior to the activity.

3. I am in agreement that those in charge may give permission for the participant (detailed above) to receive medical treatment in an emergency.

I have read and agree to the following risk statement:*

I agree

Assumption of Risks: I/we voluntarily participate in activities with Adventure Dolphin, fully understanding the dangers and risks involved in participating in such activities.

Form completed by*

Date completed*

Yes, subscribe me to your newsletter.

ADVENTURE DOLPHIHN

Adventure Dolphin is a community-led charity based in the heart of Pangbourne, right on the banks of the River Thames. We’re all about creating opportunities for people of all ages to experience the excitement of outdoor adventure, connect with nature, and build confidence through challenge and discovery.

Email: jade@adventuredolphin.co.uk

Phone: 07395 373443

Registered Charity: 1156978

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