Leisure & Culture Dundee - Adult Consent Form

Please use this consent form for adults only. Compulsory data is indicated by *

PARTICIPANT DETAILS
Title *
Forename *
Surname *
Date of birth * (dd-mm-yyyy, e.g. 01-01-1970)
Address *
Town *
Postcode *
Telephone No. *
Mobile No.
Email Address *
EMERGENCY CONTACT
Person 1
Name *
Address *
Telephone No. *
Person 2
Name *
Address *
Telephone No. *
MEDICAL INFORMATION
Please detail any medical conditions, including allergies.
Please detail any medication that you may require to carry and/or self administer.
NOTE: If you require to carry an EpiPen in case of anaphylactic shock,
you must detail this in the above spaces and meet the activity leader on the first day
of the session to demonstrate the use of EpiPen.
ADDITIONAL SUPPORT
Please detail any additional support required.
Please detail if you will require support from a carer during the class.
Yes No Please indicate if you are prone to travel or motion sickness.*
SWIMMING ABILITY
Yes No Able to swim 1 length unaided (25 metres) *
Yes No Confident in deep water *
SNOW SPORT
For snow sport courses please provide the following information.
Height
Weight
Shoe Size
PHOTO CONSENT
Please tick the box if you DO NOT give permission for your photograph to be taken.

Leisure & Culture Dundee are committed to providing quality, safe programmes and activities for all
participants through the effective implementation of policy.

Members of the public are not permitted to take photographs at Leisure & Culture Dundee events.
Leisure & Culture Dundee operates a policy of obtaining consent to enable officers and members of
the press to take photographs for official use only. Your details will be retained on a database
for use only by Leisure & Culture Dundee. These details will not be passed to any other agency
or third party.

Leisure & Culture Dundee will administer basic emergency first aid in accordance with the relevant
medical authorities. This however, will exclude administration of all medicines, except agreed
use of EpiPen.

Leisure & Culture Dundee asks participants and their carers to adhere to its
Codes of Conduct to ensure the health, safety and enjoyment of all participants. Failure
to do so could result in the participant being excluded from the class/activity. Click here
to see our Codes of Conduct that should be adhered to.

Click here to open and read declaration and click here to open and read Data
Protection Info.

I declare that the information given in this form is correct at time of writing.

I confirm that I have read and acknowledge the codes of conduct, declaration
and data protection info. *
Please tick the box if you DO NOT wish to receive information on other programmes
and activities run by Leisure & Culture Dundee.
HOW DID YOU HEAR ABOUT US?
*