Medical Declaration and Consent Form

Each participant is required to submit the Medical Declaration and Consent form below.

Thank you for your response. ✨

First Name

Surname

Phone (with country code if outside the UK)

Full Address, Postcode

Emergency Contact Name & Number

Sometimes emergency contacts numbers don’t work or pick up and this can be frustrating during an emergency, please include a secondary number just in case

2nd Emergency Contact Name & Number

Date of birth (YYYY-MM-DD)

Start date of course/session/workshop (YYYY-MM-DD)

Which course/session/workshop are you taking part in?

Do you have any medical conditions or allergies which your instructor should be aware of, which may affect your ability to participate, or which you may require sudden treatment during your course? (required)

Yes No

If answered yes, please provide further details here. I need to be aware of any medicines that you will be bringing on the day, and how best to support you (i.e Insulin, epipen)

Please include any other medical information that is relevant here

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).(required)

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.(required)

Yes

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. (required)

Yes I accept No I do not want to be in any photos

By submitting this form, you agree to the processing of your personal data in accordance with our Privacy Policy. Your contact details will be used solely for the purpose of delivering services to you by Vertical Victories, and will not be shared with third parties without your consent.

Do you consent to the GDPR disclosure agreement?(required)

I consent to having this website store my submitted information so that my enquiry can be responded to.

Consent Declaration I declare that I have read and understood all of the above information. Please write your full name and date in this boxes below

Date (YYYY-MM-DD)