(required)

    [text* Participant'sDateOfBirth class:wbk-text id:DateOfBirth]

    Does the participant have any of the following?

    Asthma or bronchitis

    Heart condition

    Fits, fainting or blackout

    Allergies to drugs or medicines

    Other allergies (foods, materials etc

    Travel sickness

    Prescribed medicines

    Is the participant receiving medical treatment?

    Has the participant recently received surgical treatment?

    Has the participant been given specific instructions to follow in case of medical emergency?

    The participant has received a tetanus injection in the last five years

    I consent to take part/ to the participant's taking part in training activities

    I understand that some of these activities may include water but I/ the participant will be under instruction at all times.

    I consent to any emergency treatment necessary during the course of the programme.

    I authorise the Course Leader to sign, on my behalf, any written forms of consent required by hospital authorities should surgical operation or serum injection be deemed necessary and, provided that delay required to obtain my signature might be considered (in the opinion of the doctor or surgeon concerned), likely to endanger the health and safety of myself/ the participant.

    How did you hear about Northney Coastal Centre?

    Poster/ flyer

    Marketing email

    Social media

    Recommended by a friend

    Northney Marina advertising

    At Releasing Potential, maintaining the security of your data is a priority. Releasing Potential uses your personal data for electronic marketing purposes (with your consent) and may send you postal mail to update you on events, courses, and general information about the activities undertaken by the organisation.

    We aim to update you about products and services which are of interest and relevance to you as an individual. To this end, you will be contacted about products and services relating to the area of our organisation in which you have shown an interest.

    We cannot keep you updated about training dates if we do not have permission to contact you. You can unsubscribe from our mailing list at any time by clicking the unsubscribe button on our emails, or by emailing us directly.

    I want to hear from Releasing Potential Coastal Centre; I give consent to being contacted about upcoming dates and events.