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Lough Allen Education Centre

 

 

Our registration form

 

We use this form to record information such as guest details, medical information, and acceptance of responsibility. This form includes a parental permission section which is relevant to all under 18 year olds.

For bookings which include under 18 year olds, we always need completed and signed copies of this form returned before the event.

For bookings on behalf of groups of over 18 year olds, we may agree to have forms completed on the day - subject to sufficient general information being provided by the organiser.

 

REGISTRATION FORM 

Tel 071-9640588   Email  alleninfo@eircom.net  

Before you fill out this form please read it very carefully. Full and accurate completion of all sections is very important. We require full disclosure of your current health. The information you give us may assist people in the unlikely event of an accident. Personal information will be treated as CONFIDENTIAL and ONLY released to others in the event of an emergency.

Only in exceptional cases will a medical condition prevent you taking part in activities.

If you are in doubt about whether this is the case, or in doubt about detailing a condition that may be irrelevant, please seek the advice of your doctor.

NAME OF PARTICIPANT ........................................................................ Age............. years

Organisation ...................................................................................................................................

At (address) ....................................................................................................................................

Daytime phone .....................................

IN CASE OF EMERGENCY, PLEASE CONTACT;

Name .................................................................Relationship..........................................................

Address..........................................................................................................................................

Home Phone....................................... Work phone :........................................................................

Do you have any condition including a disability or special need, heart condition, allergy, epilepsy, diabetes, asthma, phobia or fear, past injury, operation or illness ?

If yes, please give details. If no, please write "no".

 

 

Are you receiving any treatment or medication that we should be aware of ?

If yes, please give details. If no, please write "no".

 

 

How well can you swim ?.............................................................

 

Acceptance of responsibility

If you are completing this form as an adult participant (18 + years),

please sign below these statements ;

I accept the fact that while the course leaders are skilled and experienced, they are unable to guarantee total safety, since some risks are beyond their control.

I give permission for the course leaders to render first aid and to seek emergency medical / rescue services for me in the event of illness or injury.

I agree not to use narcotic drugs or alcohol before or during my participation in any outdoor activity.

I realise my participation is solely at the discretion of the course leaders.

I agree to follow all instructions and guidelines given by the course leaders and to act in a safe and responsible manner at all times.

Signature ........................................ Date ..................

 

Parental permission

If you are completing this form on behalf of a young person (under 18 years),

please sign below these statements ;

I am responsible for the young person named above who has my permission to participate in the proposed activities. I have completed the details above on behalf of the young person. I accept the fact that while the course leaders are skilled and experienced, they are unable to guarantee total safety, since some risks are beyond their control.

I give permission for the course leaders to render first aid and to seek emergency medical / rescue services in the event of illness or injury.

Signature ........................................ Date ..............

 

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