Moors to Mountains Participation Consent Form

Thank you for booking a place on a Moors to Mountains activity.

Please carefully read and complete the following form, which should then be submitted by each participant no later than 7 days before the activity. If you have any questions or concerns, you may contact Moors to Mountains via telephone between 10:00 and 20:00 Monday to Friday on 07535489950, by text or Whatsapp any time, or email any time via moorstomountains@gmail.com.

While Moors to Mountains offers a fun, informative and safe environment for all participants, it is important to acknowledge that all outdoor and walking activities present certain risks. A clear safety briefing will be delivered by the walk leader before the booked activity, and on approach to any potential hazards. All Moors to Mountains activities are individually risk assessed and you will have been sent a copy of the risk assessment document for this particular activity by email.

Please refer to the Moors to Mountains Terms & Conditions.

Date of booked activity

Participant Information

Participant Full Name

Please provide your forename and surname

Preferred "Nick Name"

Please do say if you would prefer to be address more casually

Email Address

Please enter your main personal email address

Mobile Telephone Number

Please enter your main personal mobile telephone number

Home Address

Please supply your home address including house number and postcode

Date of Birth

Day

Month

Year

Emergency Contact Information

Emergency Contact Name

Please provide the name of your emergency contact person

Emergency Contact Telephone Number

Please provide the telephone number of your emergency contact person

Relationship to Emergency Contact

Please state how you are related to or how you know the emergency contact

Participant Medical Information

The following section relates to your personal health, fitness and wellbeing. Please complete all relevant details in as much detail as possible. It is your responsibility to provide accurate and up-to-date medical information.

If you tick any of the three following boxes, you must provide any details that the walk leader should know in case of a medical or health related incident during an activity. All details are recorded and stored in confidence for safety reasons. Please see the Moors to Mountains Privacy and Data Storage Policy for further details.

Do you have any health/medical conditions, previous injuries or allergies that may affect your ability to participate in the activity, or which may require sudden treatment during an activity?

Yes

Are you currently using any medication that the walk leader should be aware of? This includes asthma inhalers, autoinjector pens, blood thinners etc.

Yes

Are you allergic to any medication, or are there any medications or treatments that you would not wish to receive?

Yes

If you have answered "yes" to any of the preceding three questions above, please provide FULL details of anything relevant including the name and address of your GP or healthcare provider where relevant. You will be contacted before the activity if any further discussion is required. This information should include all pre-existing medical conditions, previous injuries or special requirements that may affect your participation in this outdoor activity.

If you have a pre-existing medical condition or previous injury that may make it unsafe for you to take part in this activity, it is your responsibility to seek advice from your doctor or a medical specialist before attending.

All participants must bring any personal medication that will or may be needed on any activity, including but not limited to asthma inhalers, autoinjector pens, allergy relief, routine pharmaceuticals and feminine hygiene products.

Details of pre-existing medical conditions or special requirements.

Please provide all relevant information as requested above.

Participant Consent Declaration.

I have read and understand all of the information listed under "Moors to Mountains Participant Consent Declaration".

By ticking this box, I agree with and consent to each stipulation.

Digital Images and Media Consent Declaration.

During activities, the walk leader will take photographs or video clips of participants and scenery, to be used for publicity and marketing purposes to promote Moors to Mountains via both printed formats and online, including social media platforms.

Your personal choice to be included in such media is wholly respected.

Do you consent to being included in image or video capture?

Yes, I give my full consent.

No, please do not include me.

In the event that any participant does not wish to be included in photography or video capture, the walk leader will show discretion and advise the group before any activity to be respectful and only take pictures of themselves and any personal friends. BUT the walk leader cannot be directly responsible for the actions of other participants where taking photos is concerned.

Yes, I agree and understand.

Footwear, Clothing and Equipment Requirements

By ticking this box, I confirm that I have read and understand all of the information listed under "Moors to Mountains Footwear, Clothing and Equipment Requirements", and hereby agree to attend the activity with all necessary items.

Moors to Mountains Mailing List

I would request Moors to Mountains to contact me in future about other professionally guided activities.

Yes please!

No, thank you

On this date, I understand and accept all above consent stipulations in the Moors to Mountains Participation Consent Form

I agree to notify Colin Liptrot if there are changes to any of the supplied information before the date of the booked activity.

Participant Signature

Signature field is empty.

Please carefully read the following stipulations and tick below to acknowledge that you, as the participant understand, agree with, and give consent to each point as outlined by me, Colin Liptrot, trading as Moors to Mou...

It is imperative to wear clothing that is suitable for both the activity and the time of year. Weather conditions can change very quickly while out and about in the hills. All participants must wear sturdy footwear, approved for use for the boo...