Lee Valley White Water Centre

Young Persons Consent Form Issue 1

Young Persons Consent Form Lee Valley White Water Centre (LVWWC) Please complete section A
Section A - PARTICIPANT INFORMATION Childs Name: Address: Postcode: Day: Evening: Mobile:

Telephone:

Date of Birth: MEDICAL INFORMATION Does your child have a disability? YES/NO If yes please give details:

Does your child have any medical conditions of which we should be aware? YES/NO If yes please give details:

Does your child have any allergies? YES/NO If yes please give details:

Please detail any other information that may be relevant to their participation in this activity:

SECTION B Please complete all sections:I give my consent for the above person to take part in water activities at LVWWC I understand that some activities may be of a strenuous/adventurous nature. My child has no medical conditions which may affect their participation in these activities where relevant a medical conditions are listed above. I have read the Safety for Water Users leaflet, which can be found on the website. EMERGENCY CONTACT DETAILS (If different from section A) Full Name: Address:

Yes

No

Postcode: Day: Telephone: Evening: Mobile: Parent Guardian please delete as appropriate Relationship to child: We may occasionally film or take photographs of participants for publicity purposes, including reproduction on our website If you do not agree to us using photographs or footage that include yourself/your child, please tick the box. The parent/guardian must sign below as the participant is under 18 years of age: I, the legal parent/guardian of give my consent for my child to take part in the activities above. In the event of an incident or accident involving my child, I agree to my child receiving first aid from a suitably qualified person and/or any medical or dental treatment, including but not without limitation to anaesthetic and blood transfusion, which may be considered necessary by a registered medical practitioner. Signature : Name : Date : July 2010 Page 1 of 1