APPLICATION,
MEDICAL &
CONSENT FORM
YORKSHIRE DALES CONSERVATION RESIDENTIAL PROJECT
22nd August to 28th August 2015
Please complete in clear block capitals and leave/delete as appropriate where options are given.
Participants 18 and over can sign for themselves. Parent/guardian is to sign for under 18s.
Preferred First Name:………………………… Last Name:…………………………………
E-mail: …………………………………………………………………………………………..
Address:.…………………………………………………………………..…………………….
……………………………………….. ……………..
Tel: (Home)…………………………………
Postcode:……………………………
(Mobile) ………………………………….
D.O.B……………………………. Your e-DofE ID account number:
_ _ _ _ _ _
Award Group (Max. 2 participants from any one Group.):………………………………………………
Group Leader:…………………………………
Tel:…………………………………….........
Emergency contact (name) ……………………………………………………………………
Relationship (to participant)……………………………………………..………......…………
Address (if different):………………………………………………………………..…………..
………………………………………..…………
Postcode:……………………………..
E-mail ………………………………………..…………………………………………………..
Tel No’s (covering all hours) ......................................................……………………………………
Dietary Needs (Please be specific.)
………………………………………………………………………………………………………
………………………………………………………………………………………………………
Do you have your own toe protection boots? Yes / No Where our risk assessment
indicates toe protection boots, they must be worn. Walking boots are not a substitute in
these situations. Toe-protection boots can be loaned to participants for the week (free of
charge). If you do not have any, what size of work-boot should we lend you?
Size . . . . . . . . . . . . . . .
NOTE: It is important for the safety and well-being of yourself and others that you provide
details of ALL current and past medical conditions. It is extremely unlikely that any medical
condition would lead to your not being accepted on a DofE event.
Please give details of any medical conditions, allergies, disabilities or special needs e.g.
diabetes, asthma etc.
Please give details of any current medical treatment, including medication:
Date of last
Tetanus injection:
Surgery telephone
No:
NHS No:
Name of
GP:
/
/
I acknowledge receipt of and understand the information regarding the proposed event and
consent to the above named participant taking part. I understand the nature of the
supervision arrangements. I have ensured that he/she/I understand(s) that it is important for
his/her/my safety and for the safety of the group for him/her/me to behave in a reasonable
manner and that any rules and instructions given by staff will be obeyed.
I will inform the Course Director/Administrator of any changes in the health of the
participant/my health prior to the date of departure.
I am in agreement that those in charge may give permission for my son/daughter/me to
receive medical treatment in the event of an emergency.
I undertake to become fit for outdoor physical work and to bring clothing and footwear
appropriate to ‘summer’ in the Pennines.
Signature of
participant:
Date:
Signature of
parent/guardian:
Date:
/
/
/
/
Relationship to participant
(if applicable):
All information is kept strictly confidential
When completed, please send this form and your deposit (Cheque payable to ‘Yorkshire Dales Open
Gold’) to:
‘D of E’,
c/o Yorkshire Dales National Park Authority,
Grassington,
SKIPTON.
BD23 5LB