Medical Declaration Form

Name (Required)
D.O.B (Required)
Address (Required)
Postcode (Required)
Email (Required)
Mobile Number (Required)
Experience Date/s (Required)
Emergency Contact (Required)

Please declare any medical / physical or mental conditions, illnesses or allergies from which you currently suffer. Please include relevant medication / treatment regime.
Also state specific concerns in your ability to cope with heights, exposure to cold, sun or water. (Required)

Whilst Jacqueline & Edward take all necessary steps to ensure the safety of all participants, unfortunately accidents do occasionally occur. Participants should consider risks and be aware of hazards. It is imperative that Jacqueline & Edward staff instructions are followed.

Jacqueline & Edward accept no responsibility whatsoever for any loss or injury resulting from any persons' involvement in our panning experiences. It is understood and agreed that clients participate at their own risk.
By dating and competing the digital signature field below, I agree that I have read, understood and agree with the booking terms and conditions.
 THIS INFORMATION WILL BE TREATED WITH THE STRICTEST OF CONFIDENCE.

Data Protection Statement


Jacqueline & Edward take your privacy seriously and will only use your personal information for the purpose(s) for which you have provided it and to ensure our legal and professional obligations to provide safe outdoor adventure experiences. We will never share your information with third parties.

 We would like to contact you occasionally with details of other activities, new courses or special offers. If you consent to us contacting you for this purpose, please tick to say how you would like us to contact you:

Email
Phone
Post
Social Media
Full Name (Digital Signatue)
Digital Signature Date (Required)

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