Indemnity Form

Reservation ID

Is this Indemnity Form being filled out on behalf of a minor?

YesNo

Participant Details

First Name

Last Name

Contact E-mail Address

If the participant is a minor, please input the best contact email address for the participant whether that is their own or a parent/guardian

Date of Birth

MM/DD/YYYY

Any medical conditions?

YesNo

Medical Conditions

Please let us know of any medical conditions you think we need to know

Additional Information

Please use this box to let us know if there is anything else you would like us to know. For those attending a residential activity, please use this box to let us know of any dietary requirements.

Emergency Contact Details

First Name

Last Name

Address Line 1

Town/City

County

Postcode

Country

Emergency Phone Number

Emergency Email Address

Photo and Media Release

The Andrew Simpson Foundation has my permission to use my own and/or my child’s photograph publicly to promote the Foundation’s and Watersports Centres work. I understand that the images may be used in print publications, online publications, websites, presentations, and social media. I also understand that no royalty, fee or other compensation shall become payable to me by reason of such use.

YesNo

Agreement

By signing this agreement I confirm that I have disclosed all medical conditions, I will wear an appropriate buoyancy aid and any safety equipment that has been issued at all times when on the water & follow instructions given by the Andrew Simpson Centre Team. Although I am covered for 3rd party liability by Andrew Simpson Centre insurers, I understand that owing to the nature of the sporting activity, the Andrew Simpson Centre Team cannot take any liability for personal injury or other damages unless proved negligent.

Please confirm the person submitting this form is over 18

Yes

Your First Name

Your Last Name