Indemnity Form

Participant Details

Participant's First Name

Participant's Last Name

The following data may be used for impact reporting. This enables us to measure our impact and secure funding for future projects. Thank you for your help in measuring this.

Your information will never be sold, licensed, loaned or otherwise distributed to any other organisation unless we are required to do so by applicable law or where we have your consent. For more information please see our Privacy Policy on our website.

Date of Birth

DD/MM/YYYY

Does the participant have any special educational needs or disabilities (SEND)?

If yes, please specify

Does the participant have any medical conditions, or require any specific accommodations or adjustments?

Please ensure you let us know any relevant medical conditions, specific accommodations or adjustments that may affect the participants ability to take part in the activity.

If yes, please specify

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

Primary emergency contact

Emergency Contact Full Name

Emergency Phone Number

Emergency Contact Relationship

Alternative Emergency Contact

Alternative Emergency Contact Full Name

Alternative Emergency Phone Number

Alternative Emergency Contact Relationship

Demographics

The following questions are optional, by answering them you will help us to understand the demographics of our customers.

Gender

Please self describe the participant's gender using the box below

Ethnicity

Please let us know the participant's ethnicity using the box below

Nationality

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 Andrew Simpson Group's 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 centre team. Although I am covered for 3rd party liability by Andrew Simpson Foundation and Group insurers, I understand that owing to the nature of the sporting activity, the 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