Please complete the form below and if you have any additional questions or queries, please contact us here. Please use this form to provide relevant medical and other details to us before your activity. If submitting on behalf of under 18s, their details can be added below to a parent or legal guardian's form.* First name Last name Names of any children you are signing the form on behalf of (only to be completed by legal guardian)Email address* Your name and relationship (if completing on behalf of a child)Activity booked* Rock climbing Abseiling Caving Archery Bushcraft Navigation Team building Navigation training Date of activity booked*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920It is a requirement of our insurers that the following are not permitted to participate in Rock Climbing or Abseiling: Anyone under the influence of alcohol or drugs Anyone who is knowingly pregnant Anyone who has had an operation within the past twelve months that, through participating, could aggravate the object of the operation Anyone undergoing medical treatment for an ailment that may be aggravated, including but not limited to high blood pressure, epilepsy, back problems, neck problems or any heart condition Anyone suffering from any other condition that may be aggravated If you are unsure, please consult your GP or medical specialist. Do you have any disability, health, medical conditions or other issues that we need to be aware of in delivering the activity? This includes bone and joint injury, reduced or impaired mobility, asthma, anaphylaxis, diabetes, epilepsy, heart conditions*YesNoPlease provide additional detail below including who the condition affects if you are signing on behalf of yourself and a child/ren:Is there any emergency medication you should be carrying during the activity, e.g. asthma inhaler, adrenaline auto-injector? We are unable to take you on any remote activities if you do not have emergency medication that you have declared.*YesNoPlease provide additional detail below including who requires emergency medication if you are signing on behalf of yourself and a child/ren:Emergency contact name* First Last Emergency contact email* Emergency contact telephone number*Relationship / connection to you?*Will your emergency contact be present on the activity?*YesNo Privacy Notice Borderlands Outdoor stores health and medical information for the purpose of ensuring your wellbeing on our courses. Contact details are used for the purpose of course administration. For more details on how we use your information, please contact us by any of the contact methods below. Acknowledgement of Risk Our responsibility to you: Borderlands Outdoor takes all reasonable steps to minimise the risk of harm in our activities including undertaking thorough risk assessments and using qualified, experienced staff. The nature of our activities though means that there is an underlying risk from factors outside our control. Some examples include slips and trips on uneven ground, rockfall during our climbing and abseiling activities and extreme weather. Minor bumps, scrapes and bruises are a normal part of many of our activities and are to be expected. We cannot be held responsible for any incidents that occur as a consequence of participants’ failure to follow the instructions of our staff. Your responsibilities: I hereby declare that I am fit and able to participate in the activity. I do not have any medical conditions or injuries that could be aggravated by my participation in this activity. I understand and acknowledge that adventurous activities and training carry a residual risk of harm that cannot be eliminated entirely. I hereby take responsibility for my decision to participate in these activities. I agree to comply with all instructions of Borderlands staff during the activity. This does not remove the responsibility that Borderlands Outdoor has to take all reasonable steps to safeguard me from harm. E signature by participant (or legal guardian if aged below 18)*Activity dates