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PSRC Medical and Consent Form 20230727

David Wright is participating in a paddlesport safety and rescue course on July 29th 2023. He has British Canoeing membership and will use a kayak. His emergency contacts are his spouse Lisa Wright and sister Susan Smelt. David is allergic to penicillin but does not have any other medical conditions or need medication. He consents to the terms of the course and provides his medical information and signature.

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bigdog99bc
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29 views

PSRC Medical and Consent Form 20230727

David Wright is participating in a paddlesport safety and rescue course on July 29th 2023. He has British Canoeing membership and will use a kayak. His emergency contacts are his spouse Lisa Wright and sister Susan Smelt. David is allergic to penicillin but does not have any other medical conditions or need medication. He consents to the terms of the course and provides his medical information and signature.

Uploaded by

bigdog99bc
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Paddlesport Safety and Rescue Course

Emergency Contact, Medical & Consent Form.

Event / Trip Details: Paddlesport Safety & Rescue Course @Rother Valley Country Park

Event Date: 29th July 2023

British Canoeing C Membership (Y) . Preferred Craft. KAYAK CANOE SUP SOT
Happy To Use All or Any
If Yes, BC Membership Number 264132

Participants Details

First Name: David Second Name: Wright

Date of Birth: 09/08/1958 Tick if Under 18


or requires legal guardian consent

Telephone Number(s) Mobile: 07935 446183

Landline: N/A

Email Address: bigdog99bc@hotmail.com

Legal Guardian / Consent Details

First Name: Second Name:

Telephone (Mobile): Telephone (Landline):

Email Address:

Emergency Contact Details

Emergency Contact # 1 Emergency Contact # 2

First Name: Lisa First Name: Susan

Second Name: Wright (Spouse) Second Name: Smelt (Sister)

Telephone Number:07935 445273 Telephone Number: 07932 313736

Email Address: bigdog99bc@sky.com Email Address: smelt38@btinternet.com


Participant / Legal Guardian Consent

double click on the and place a to confirm consent

I acknowledge receipt of and understand the information regarding the proposed course, event or
expedition and consent to the above-named participant taking part.

I will inform the event organisers in writing of any changes in the health of the participant/my health
prior to the date of departure.

I authorise the event instructor/leaders to take emergency decisions on my behalf, including the giving
of permission for medical treatment on the advice of the medical authorities’ present having taken the
following medical information into account.

I understand that participation in this activity will be physically demanding and that I may need to
carry my own provisions for part of or the entire activity

I understand that outdoor activities such as this activity can carry a risk of personal injury and in
extreme cases, the possibility of fatality.

I understand that the event tutors, instructors and leaders have Public Liability Insurance and that I can
request a copy of this. No insurance is offered for the loss or damage to personal property during the
activity.

I understand that participants may not be supervised at all times. I have ensured that he/she/I
understand(s) that it is important for his/her/my safety and for the safety of the group for him/her/me to
behave in a reasonable manner and that any reasonable rules and instructions given by trip leaders/coaches
will be followed.

I give my permission for any photographs taken whilst involved in the event/activity, to be used for
display or publicity purposes and may also be used on promotional material.
Medical Declaration

Do you, or have you ever suffered from any of the following? (please those that apply)
PLEASE BE HONEST WITH YOUR ANSWERS TO HELP US, SHOULD AN EMERGENCY ARISE (All information provided will be treated with the strictest of confidence.)

Heart Conditions Asthma. Epilepsy

Arthritis. Diabetes. Hay fever

Skin Conditions. Food Allergies. Food intolerance

Allergies (other) Haemophilia. Migraine

Other

If you have any of the above or have any other medical condition which is not mentioned
please specify below:

I am allergic to penicillin.

If you are on any medication or carry any medical aids i.e. Inhaler, EpiPen, Medical Warning
Card etc. Please specify below:

None

Do you have any dietary needs i.e. vegetarian, gluten free etc.? Or food dislikes

No

Participant / Legal Guardian Signature:

Date: July 27th 2023

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