Medical Declaration Form

Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

Country

(###)

###

####

Date of Birth

MM

DD

YYYY

Start Date of Course/Session/Workshop *

MM

DD

YYYY

Do you have any medical conditions or allergies which your instructor should be aware of, which may affect your ability to participate, or which may require sudden treatment during your course? e.g. nuts *

Yes

No

Emergency Contact Full Name *

First Name

Last Name

Emergency Contact Phone Number *

Country

(###)

###

####

Emergency Contact Phone Number (Secondary) *

It has been known for emergency contact's numbers to not work and this can be frustrating during an emergency! Please write a secondary number just in case

Country

(###)

###

####

I consider myself to be fit and in good health and there is no medical reason why I should not participate in the activities offered. In the event of an accident during my activity, I give full permission for the instructors, who is suitably trained in First Aid, to administer whatever First Aid treatment they deem appropriate under the circumstances (except as listed above). *

Yes

No

Please read the following statements carefully: I realise and accept that rock climbing, trail running and walking are activities which carry a danger of personal injury. I am aware of and accept these risks and will be responsible for my own actions and involvement in such activities.   While on the course and in the care of my instructor, I agree to abide by any instructions and decisions made by the instructor regarding individuals and the group as a whole. If I choose to disregard any advice given by the instructor before, during or after the course, I do so voluntarily and accept liability for all resulting injuries or damage.  I understand that my instructor and Vertical Victories accepts no responsibility for accidents or injury to participants or for loss of or damage to personal effects, unless caused by negligence on the part of my instructor. Please tick to accept the above statements *

I accept and understand.

Yes

No

Marketing and Social Media During activities your instructor may take photographs. These photographs may be used for publicity and marketing purposes in the future. Please check the box below if you are happy for your photograph to be taken. *

I accept

Yes

No