Consent form

Please complete the following form prior to attending your course or activity.

* indicates required field

Your name:*

Company name (if relevant):

Your email address:*

Your telephone number (mobile):*

Your address:*

Date of birth:*

Course or activity that you are taking part in:*

Date of course or activity:*

Do you suffer from any medical or physical condition that we should be aware of? (if yes please give details, including details of any associated medication or treatment):

Please provide details of an emergency contact for the duration of your course/activity.

Name of emergency contact:*

Relationship of emergency contact to you:*

Telephone number of emergency contact:*

I declare that I am in good health and consider myself fit and able to take part in the above activities.

I recognise that climbing, abseiling, hill walking and mountaineering are activities with a danger of personal injury or death. As a participant in these activities I am aware of and accept these risks and I am responsible for my own actions.

I acknowledge that Lakeland Ascents accepts no responsibility for accidents or injury to participants, or for loss or damage to my personal effects, unless caused by negligence of the service provider.

I understand that Lakeland Ascents may take photographs that contain my image over the course of the event and that those photographs may be used by the service provider in future marketing material and on various social media platforms to aid the promotion of Lakeland Ascents. If you do not wish for your photograph to be taken, please let your instructor know.

I have read and I agree to the above conditions and disclaimers*

Print name (this is the equivalent of you providing an electronic signature):*

Date:

We strongly recommend that you have appropriate insurance cover for the activities that you will be taking part in. Consider cover for unforeseen last minute cancellation, personal accident, third party liability and loss or damage of your personal possessions.