Please fill out the following form to help us understand your physical condition.

Please select any of the dietary requirements below and state the total number of people it applies to in your group:

MEDICAL DISCLAIMER
Individuals must NOT participate in activities if any of the following applies to them. If you have written approval from your doctor, we will need to see this before taking part:
▪ High or low blood pressure
▪ Heart disease or any other cardiovascular problems including undiagnosed chest pain
▪ Breathing difficulties (including asthma) where it is not satisfactorily controlled by medication
▪ Frequent episodes of feeling faint or dizzy or taking medication which may cause drowsiness
▪ Back pain or limited movement in any joint
▪ Currently pregnant or recently given birth


DECLARATION
▪ I can confirm that I have received individual consent from every participant which allows them to take part in the activities at Mount Cook Adventure Centre
▪ I have also communicated and included any further information I deem relevant about participants; this could range from personal to mental health issues
▪ I understand that Mount Cook offers a range of outdoor activities which can never be entirely risk free and have communicated this to all parents/participants
▪ I give permission for any medical treatment deemed necessary to be given to ensure the wellbeing of participants
▪ If necessary, and required by Mount Cook individuals will complete individual forms
▪ I can confirm that the information I have provided is correct and complete. I will inform Mount Cook Adventure Centre as soon as possible if there are any changes to this


AS THE GROUP LEADER YOU WILL BE EXPECTED TO;
▪ Act in loco parentis during your stay at Mount Cook and take full responsibility for individuals
▪ Bring all completed individual consent forms along on the trip, including next of kin information
▪ Communicate all relevant issues about participants which may affect delivery
*All adults will be required to sign a disclaimer before participating in activities.

Your Signature

GROUP LEADER FORM

This form must be completed by the assigned group leader on behalf of all guests who are participating in activities.
The purpose of this form is to ensure Mount Cook can accommodate individual’s needs. We may need to tailor sessions to be inclusive of everyone, so please tell us as much relevant information as possible.

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Mount Cook Activity Limited is a company limited by guarantee registered in England and Wales. 

Company registration number: 08906431  | Registered address: 57 Ashbourne Road, Derby, DE 22 3FS  | VAT registration number: 241628125