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MEMBERSHIP AND CONSENT FORM

For young people under 16 yrs, this form must be completed by parent(s) or guardian(s) in the presence
of a Dynamix member of staff or volunteer, or signed by parent(s) or guardian(s) and countersigned by a
responsible adult witness.

Skateboarding, BMX, Inline skating, Scooting, Trials Riding, Circus Skills & Free-running are
hazardous activities; All members are strongly recommended to wear full protective clothing –ie.
kneepads, wrist guards and elbow pads. Helmets MUST be worn for ALL wheeled sports activities
and Stilt -walking. Dynamix Extreme will supervise the park with qualified First Aiders and volunteers but
it cannot accept any responsibility for accidents which may occur as a result of the activities of
Skateboarding, BMX riding, In-line skating, Scooting, Trials Riding, Circus Skills or Free-running.

Rules/Terms and Conditions, to be observed by members, on the back of this form.

By signing below, I agree that:


I have read the Terms and conditions and rules, and understand and accept that I am/my child is
using the facilities entirely at my/her/his own risk, and, when less than 16 years old, with a
parent’s/guardian’s knowledge. In accepting this risk I agree to waive any legal entitlement to
claim against Dynamix Extreme, its staff or volunteers, for injury or loss or damage to personal
property, unless caused by negligence of Dynamix Extreme.

May any film footage or photographs taken of you/your child be used either for publicity or
displayed at the park?
YES…….. NO……….

Do you/does your child have any medical conditions, eg, epilepsy, asthma, etc
which we should know about in the event of an accident? Please include any
allergies which could affect treatment, or any reason why you should not be
doing physical activity.

…………………………………………………………………………………………………………………

Member’s Name (Print clearly)……………………………………………… D.O.B ……………..........

Signature of Member (if 16 yrs or over)……………………………………………………………………

Signature of Parent/Guardian ……………………………… Witnessed


by………………………

Print Name…………………………………………………………… Print


Name…………………………….

Address……………………………………………………………….
Address…………………………………
………………………………………………..
……………………………………….......
Next of Kin Telephone Numbers (Essential)
Home ……………………………………… Work ……………… …. Contact
Tel……………………

Mobile ……………………………………… E Mail


Address: ...........................................................................................
Registration Date (when form signed)…………………

Dynamix Extreme, at Albany Rd, Gateshead, NE8 3AT www.dynamixextreme.com Tel: 07793045420 or
07855110906 | Company Number 06362932