Customer Consent - Survival Courses for Wilderness Living

Full Name*

Full Postal Address*

Postcode*

Telephone Number*

Email Address*

Date of Birth*

Vehicle Registration

Title of Course*

Date of Course*

I UNDERSTAND THAT

The survival course can be physically and mentally demanding and may require excessive exertion and that I will not bring any alcohol or non-prescription or over the counter drugs. The possibility of personal injury to me and others exists. The course may expose me to hazards (fire making and cutting instruments, cold and/or heat).

I CONFIRM AND AGREE

I am aware of the risks to myself and others whilst attending a Survival School survival course and agree to abide by the rules at all times. I am physically fit and mentally able to partake in the survival course. If I feel unwell to continue I shall alert a member of staff immediately. I agree to comply with the rules as given to me by Survival School staff, to use all equipment as instructed and to obey all directions given by Survival School staff.

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Notes

Do you have a history of any other illness or learning difficulty not mentioned above? If so, please state illness below:

Are you under any medication at the moment? If so please state current medication.

Emergency Contact

Emergency Contact*

Postal Address*

Postcode*

Relationship*

Emergency number 1*