Consent Form

Student Name

Date of Birth*

Phone Number*

Your Email*

Your Address*

Post code*

Dietary requirements*

Name*

Relationship*

Main Contact Number*

Mobile Number*

It is your responsibility to make known any potential medical conditions that may effect you during the activities associated with the programme you will be taking part in. Please therefore provide as many details as possible. This information will be shared with the instructors and coaches at Phoenix Services only.

Medical Information

Have you ever suffered from any of the following conditions:

Asthma/ Bronchitis (wheezing with breathing or wheezing with exercise)Heart Conditions (Angina, heart surgery or blood vessel surgery)Fits, fainting or blackouts (Epilepsy, seizures, convulsions or take medications to prevent them)Severe headaches (Recurring migraine headaches or take medications to prevent them)DiabetesTravel sickness or Motion sicknessClaustrophobia or Agoraphobia (fear of closed or open spaces)Allergies to MedicationAny other allergiesOther (specify below)

Any other allergies?

Other Illnesses or Disabilities?

What blood type are you?*

Are you pregnant?

Are you suffering/ recovering from any injuries? i.e. back, arm or leg problems following surgery, injury or fracture, which may affect your time at the training centres?*

Do you have a pacemaker?

What year did you have a tetanus vaccination?*

Are you currently taking any prescribed or non-prescribed medication? If so please specify*.

Consent

I understand that the training centres are under no liability in respect of any personal injury I may sustain during the course. If I wish to have personal accident cover, I shall arrange insurance before arrival.

In an emergency situation I authorise the organisers to take me to hospital and give my full permission for any treatment required to be carried out in accordance with the hospital’s diagnosis. I understand that my emergency contact person witll be contacted, as soon as possible, of the hospital visit and any treatment given by the hospital if necessary.

The information I have provided about my medical history is accurate to the best of my knowledge. I agree to abide by the conditions of booking and any rules published by Phoenix Services. I acknowledge that this information will be held (in the strictest confidence) on record until the course is completed.

Signed* Please type your name.

Student Details

Emergency Contact

Medical Information

Consent