Activity you have booked with us

Activity Start and End Dates

Full Name

D.O.B

Street Address

Street Address line 2

Town

County

Postcode

Email

Telephone

Please outline any experience you have?

EMERGENCY CONTACT

Name

Relationship to you

Contact Number

MEDICAL DISCLOSURE

Please rate your physical condition

PoorFairGoodExcellent

Please select your swimming ability

Can't SwimNoviceIntermediateAdvanced

Do you have any medical conditions you wish to disclose (in confidence) to Exped Adventure?

YesNo

If YES please provide details

Are you currently taking any medications regularly?

YesNo

If YES, please list the medications name, dosage, and how often it's taken

Do you have any special dietary requirements (if relevant) ?

YesNo

If YES, please provide details

PHOTO RELEASE

Exped Adventure has my permission to use photographs/images of the participant named above for commercial purposes in print and online publications and social media. I understand that no royalty, fee or compensation shall become payable to me by reason of such use.

YesNo

DECLARATIONS

BMC Participation Statement

"The BMC recognises that climbing and mountaineering are activities with a danger of personal injury or death. Participants in these activities should be aware of and accept these risks and be responsible for their own actions and involvement."

• I have read the Challenge or Course description (if relevant) and the UK booking conditions and I accept these booking conditions in full. I am aware that participation in adventurous activities entails some risk of injury. Exped Adventure staff are trained, insured and qualified to run activities, however, participants accept that accidents and injuries may occur. By submitting this form you also understand it is your responsibility to organise appropriate insurance cover for this booking.

• I agree that the above information is true and accurate to the best of my knowledge.

• I understand that my medical information will be kept confidential and every effort will be made to consult me beforehand should any disclosures be deemed necessary.

• I agree that should I become incapable of giving consent for disclosure of essential medical information in the event of an emergency, information may be imparted at the discretion of the medical team acting in my best interests.

• I agree to discuss/disclose to the organisers any injury or illness occurring between this date and the date of departure.

YesNo

Name

Date