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

Personal Details
NEXT OF KIN DETAILS

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, 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 agree to take part in the activities at Mount Cook Adventure Centre and understand that these can never be entirely risk free
▪ I have communicated all information I deem relevant about myself to the Mount Cook team; this could range from personal to mental health issues
▪ I give permission for any medical treatment deemed necessary to be given to ensure my wellbeing
▪ The information I have provided is correct and complete and I will notify Mount Cook if any of this changes prior to activities

Your Signature

INDIVIDUAL FORM

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