Please fill out the following form to help us understand your physical condition. Please remember to include group leader medical and dietary information in the below. Please list all the medical conditions, non-food allergies or learning difficulties for the group below. Please group asthma, eczema, hay fever, ASD etc together in one field, e.g x 4 children with asthma. Please list any food related allergies in the dietary requirements section. Please select any of the dietary requirements below and state the total number of people it applies to in your group. If you have none, please set the number to 0: Please remember to include group leaders/staff dietary information in the below.
To your knowledge does anyone within your group wear a turban or other headwear/religious clothing which would restrict them from wearing a helmet or other PPE?
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
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.
PRIVACY NOTICE: This form will be kept securely and will be destroyed after 6 months if no incidents occurred during your stay. If an incident has been recorded, we may hold this data for up to 7 years (up to 20 years for U16’s) I declare that the info I’ve provided is accurate & complete Submit Thanks for submitting! You will receive a confirmation email to confirm you have successfully completed this form.