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Medical Form
Risk and Responsibility Declaration
Outdoor activity provision in the UK has an enviable safety record. However, accidents can occur and we ask that all clients complete the following declaration. This does not affect your statutory rights. I understand that there are risks associated with all adventure activities due to the environment, the sport or the logistics of the day. I have had access to Wales Outdoors risk assessments at www.walesoutdoors.co.uk and I am satisfied that the proposed activity provision will be as safe as it can be. I am also aware that accidents can occur and I accept the inherent risk involved in taking part in adventure sport. I also accept that I have a responsibility during the activities to behave in a reasonable manner and to act in accordance with the leaders instructions.

Insurance
Wales Outdoors Limited has public liability insurance to 5 million, the social services standard. Please note that this cover does not provide compensation for loss of earnings where Wales Outdoors is not liable. We strongly recommend that all clients take out personal activity insurance to cover these losses should an accident occur.

Medical Form
The information on this form will be treated in confidence. It is required only to enable us to give appropriate medical help and support, if needed. It is important that you answer the questions fully and honestly.



Group Leader Name:

Date of Activity:

Your Name:

E-Mail:

Address:

City:

County:

Post Code:

Country:



Emergency Contact Name:

Emergency Telephone Number:

Any regular chest pain?:
Yes
No

Cough, wheezes, shortness of breath?:
Yes
No

Abdominal pain?:
Yes
No

Fits - convulsions?:
Yes
No

Do you have any illnesses:
Yes
No

Do you smoke?:
Yes
No

Can you swim?:
Yes
No

Any Medication - If so, what?:

Any Allergies - If so, what?:

Date of Birth:

Recent Medical Examinations? If so, for what?:

Anything Else?:

Shoe Size:

I declare that the above answers are true and that I have not witheld any relevant information - Please initial:



Can we add you to our mailing list?
Yes
No





 
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