Consent Form

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Consent Form

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

Email *

Your name *

Your telephone number *

Mobile please, so we can get in touch if there are any last minute issues or changes of plan

Your address *

Your date of birth *

YYYY

Course or activity that you have booked *

Date of course or activity *

If your course or activity is split over multiple days, please use the start date.

YYYY

Which slot? *

Morning

Afternoon

All day

Split over multiple days

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

Name of emergency contact *

Relationship of emergency contact to you *

Telephone number of emergency contact *

Disclaimer

I declare that I am in good health and consider myself fit and able to take part in the above course or activity. I recognise that taking part in climbing, abseiling, hill walking, mountaineering and other adventure activities comes with a risk of personal injury or death. As a participant in these activities I am aware of and accept these risks and I understand that 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 the negligence of Lakeland Ascents.

Disclaimer continued

I understand that Lakeland Ascents may take photographs that contain the participant(s) 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 photographs to be taken, please let your instructor know.

Insurance recommendation

We strongly recommend you have appropriate insurance cover for the activities to be undertaken. Insurances that we recommend are personal accident, third party liability and contents insurance covering your personal possessions. We also recommend that you consider insurance that will protect you should you have to cancel the activity close to the activity date, resulting in a loss of your activity fee.

I have read and I agree to the above conditions and disclaimers. I note the advice regarding insurance. *

Agree

Required

Print name *

Printing your name here is the equivalent of an electronic signature.

Today's date *

YYYY

A copy of your responses will be emailed to the address you provided.

Submit

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