EASTER CAMP MEDICAL FORM 2023
This form is to be completed by the Parent / Guardian of each Child. Or adult attending
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Name of Rider *
Date of Birth  ( if under 18)
MM
/
DD
/
YYYY
Age of Rider *
Name of Parent or Guardian *
Emergency Contact 1 *
Emergency Contact 2 *
Doctor's Name, Address and Telephone number *
 Medical Conditions  - Please tick below *
 Medical Conditions  - If you have ticked any of the above please provide further details
Do you wear Contact Lenses *
Religion if applicable to Medical Treatment
Any other details the Welfare Officer should be aware of?
Have you experienced any recent or previous injuries/ operations / Medical Treatments? *
If you ticked YES to above please provide details
Date of last Tetanus Injection
MM
/
DD
/
YYYY
Any adverse reaction to the Tetanus injection
Clear selection
Any adverse reaction to the Tetanus injection Details
Blood Group ( if known)
Dietary Requirements
Clear selection
Dietary Requirements - Further details if selected Other
Emergency Medical  / Dental Treatment
In the event of my daughter/son requiring emergency medical or dental treatment whilst taking part at camp activity as described above, and an officer or other responsible adult being unable to contact either myself or other person with a parental responsibility for my daughter/son. I hereby authorise Jill Holt or other officer of the Camp to obtain such medical or dental treatment for my child as they, in their absolute discretion, think necessary after consultation with a medical or dental practitioner. This authority extends to all medical and dental treatment including the giving of an anaesthetic where necessary
Emergency Medical / Dental Treatment   *
Liability Waver Agreement
By attending the camp, I agree to the following : Jill Holt will take every reasonable care to ensure that the camp is both fun and safe; however, I understand that when undertaking the riding, as is the case with any physical activity, the risk of injury is always present and cannot be entirely eliminated.

I have fully disclosed to Jill Holt any conditions that I have or may have prior to participating in the camp. Whilst it is acknowledged that personal injury and/or death resulting from negligence cannot be legally waived, I release and waive any other claims for negligence, that I may now or hereafter have against Jill Holt. I agree that I am responsible for safeguarding my own personal belongings and Jill Holt will not accept liability for personal property which has been lost, stolen or damaged during the camp.
Liability Waver Agreement *
Required
GDPR - Data Protection
 The data provided by you to Jill Holt on the registration form will be stored and processed in order to:

• Ensure Jill Holt has up to date medical information  
• Contact you in the case of medical emergencies and/or any concerns about your child;

You may change your mind at any time.

If you wish to withdraw your consent notify Jill Holt at

The information will be deleted after the camp
GDPR - Data Protection *
Required
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