HEALTH AND CONSENT FORM Please only complete what you feel comfortable adding and that you feel is relevant. CONTACT DETAILS: Full Name: Home address: Postcode: Email: Date of birth (dd/mm/yy): Mobile number: Home number: Emergency contact name: Emergency contact number: Relationship to emergency contact: HEALTH INFORMATION: Relevant health issues and medication needs: Any known allergies: Specific advice to follow in case of an emergency: ADDITIONAL INFORMATION E.g. learning or behaviour needs, access, support, dietary requirements, phobias DATA PROTECTION • Outside Lives Ltd (OL) is fully compliant with GDPR and is registered with the Information Commissioner’s Office (ICO) • Outside Lives Ltd will retain your information for a maximum period of two years after completion of your project / course. • All health forms are confidential and are kept in a secure storage box. Information on this form will only be shared with OL leaders, or other medical staff, in the event of an accident or emergency. I GIVE OUTSIDE LIVES PERMISSION TO: (Y/N ANSWER) Add me to their mailing list (no details provided to third parties) Take photos/films whilst I am involved in any workshops/courses* Use photos/films of me on OL website and social media platforms* Use photos/films of me in relevant OL publicity material and press releases* *Parent/guardian consent required where child is under the age of 18. I CONSENT TO (Y/N ANSWER) First Aid being administered by qualified leaders & medical staff if needed Signed: Date: Please sign & return your completed form to [email protected] Outside Lives Ltd, Aberduna Hall, Maeshafn Road, Gwernymynydd, Mold CH7 5LE
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