Activity consent form

Please complete this form and submit it prior to your activity day/first day of your course. Please note that you will not be able to participate in any activities until one completed consent form per participant has been received.

Participant details - one per form.

Participant first name:

Participant last name:

Date of Birth:

Email address:

Address:

Postcode:

Contact number:

Emergency contact - for duration of course

Emergency contact name:

Relation to participant

Emergency contact mobile number:

Medical conditions / injuries / illness

We kindly ask that any medication left in our care is clearly listed on the consent form, along with information on what it is for and when to be administered. Please also state clearly if medicines left at the centre must accompany the participant at all times (on land and water), or can be left at a central location within the centre. If the medication must stay with the participant at all times (on land and water), you must provide a dry pack for the medication.

Does the participant have any medical conditions/ injuries/ illness that we should know about?:

Yes
No

If yes, please disclose here (1):

Allergies / food intolerance's

Does the participant have any allergies or allergic to food/medication which we should know about?

Yes
No

If yes, please disclose here (2):

Does the participant take any medication which we should know about?

Yes
No

If yes, please disclose here (3):

Additional needs

If applicable, please provide details of any additional needs.

Yes
No

If you require any additional adjustments to be made we must be contacted prior to booking on 0118 934 4424.

If yes, please disclose here (4):

If you wish to opt in to receive further information about Dinton Activity Centre or Countryside Service, tick the box

Yes
No

Photography Consent

We may use your use your photograph, film and words to publicise events, in newspaper articles, magazines and other media such as websites and Intranets, social media, information leaflets, marketing materials such as posters and displays, electronic newsletters and presentations

You can contact Dinton Activity Centre at any point and ask us not to use your photograph, film or words.

Do you consent to the participant being photographed for publicity?

Read our terms and conditions, below.

Terms and Conditions (PDF document)

Terms and conditions:

I have read the terms and conditions

Signed: (Person taking part in the activity or parent/guardian):

Date:

Declaration:

By ticking this box I consent to the use of my electronic signature in lieu of an original signature on paper.

You do have the right to request that you sign a paper copy instead, however by ticking this box you are waiving that right. You have the right to submit a written request to obtain a paper copy of the electronic form and electronic signature.

Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. Please ensure you update us of any change to your contact details so we can get in touch with any changes, if necessary.