First Name

Surname

DOB

Contact telephone number

Email Address

Please tick all that apply: Please tick all that apply: Asthma Angina Arthritis / Joint pain Back pain Chest pain Diabetes Epilepsy Echzema Hayfever Heart disease High Blood Pressure Migraines Vertigo Dietary requirements (Specify below) Allergies (Specify below) Mental ill-health (Specify below) Other (Specify below)

Additional details, dietary requirements or medical issues not listed above...

Next of Kin: Name

Next of Kin: Relationship

Next of Kin: Contact number

In booking my child onto this course I understand that all activities take part in a wild woodland environment and that some of the activities will involve the use of fire and sharp tools and equipment. Whilst the team at Survive & Revive will do our very best to safeguard and support young people to interact safely with the woodland, their tools and the hearth fire, minor injuries such as cuts and scrapes may still occur. In booking my child onto this course I understand that all activities take part in a wild woodland environment and that some of the activities will involve the use of fire and sharp tools and equipment. Whilst the team at Survive & Revive will do our very best to safeguard and support young people to interact safely with the woodland, their tools and the hearth fire, minor injuries such as cuts and scrapes may still occur. I Understand

Have you provided us with all the information we require to keep you child safe? Have you provided us with all the information we require to keep you child safe? In booking my child onto this course I have provided all relevant information that is required for the team to keep my child safe for a days activity in the woods. Please can a member of the team contact me to discuss in further detail?

Throughout the course/event we may take photographs and short video to use for marketing purposes on both our website and social media. Please indicate your preferences below. Throughout the course/event we may take photographs and short video to use for marketing purposes on both our website and social media. Please indicate your preferences below. I consent - Make my child famous! Consent is fluid - ask my child on the day! I consent but please only send them to me. I do not consent for my child to be photographed or filmed.

Would you like to be added to our mailing list to hear about upcoming events and receive occasional offers? Would you like to be added to our mailing list to hear about upcoming events and receive occasional offers? Add me! No way!

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