Indemnity Form - Clyde Muirshiel Regional Park
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2Indemnity Form
Please complete and bring on the first day of the activity/course, your participation may be effected if you do not.
Course:.......................................................................................……….…………….................................…..
Dates and Times:.......................................................................……….……….................................………..
Please fill in below the name, address and telephone number of the participant.
Name: .......................................................................................................……………………………...……….
Address:....................................................................................................…………………………….…..….….
........................................................................................... Post Code.....................……….…………..….…..
Day Tel: .........……………..…… Eve Tel: …......…………..…… Mobile: …….….………………………..…....
E-mail Address:................………………….....………………………………………………………………….......
1. Do you have any medical conditions, allergies or injuries that might impact on your participation?
Yes
No
If yes, please give details ………………………………………………………………………….......….
2. Do you take medication for your condition?
Yes
No
If yes, please give details .............................................................................……...........……………
3. Are you confident in water?
Yes
No
All activities are potentially hazardous. The Park Authority takes all reasonable precautions to
prevent any such incidents.
Clyde Muirshiel Park Authority shall not be liable for any loss or damage to goods, property,
equipment, clothes or any other articles brought onto the premises by the lessee or third party.
4. We sometimes take photo's and video to use in Park publicity.
Do you have any objection to this?
Yes
No
5. We can use this contact information to inform you of new courses or special offers.
Do you have any objection to this?
Yes
No
Please fill in below the name and address of your next of kin:
Name:..................……......................................…… Relationship: …………….………………….........….…
Address.................................................................................................……………………………........………
.............................……......................................................... Post Code: ..................……………………….
Day Tel: ……..……………..……… Eve Tel: ….….......….………..…… Mobile: …...….….……………………
I, the undersigned declare that I have read and understood the following information, hygiene advice and
disclosed any medical condition which may affect my/my child’s ability to participate in this course.
Print name …………………………………………............……………………………………....…………………
Signed:..............................................................................Date:.................................………………………….
(Must be signed by the responsible person over 18 years)
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