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course joining form

COURSE REGISTRATION & MEDICAL FORM



Course Name

Student's Personal Details
Your Name (required)
Please Enter your Age (required)
and Date of Birth (required)
Your Home address (required)

Your Email (required)

Phone Numbers

Emergency Contact Personal Details
Parent, Guardian or Next of Kin (required)



Emergency Contact Address

Your Doctor's Name (required)

Your Doctor's Phone Number

Medical declaration

It is your responsibility to make known any potential medical conditions that may affect you during the activities associated with the training programme or event you are taking part in. Please therefore provide as many details as possible. This information will be shared with the organisers and coaches at training and events.

Have you ever suffered from any of the following conditions

Asthma/bronchitisHeart conditionsFits, fainting or blackoutsSevere headachesDiabetesAllergies to medicationFood allergiesAny other allergiesOther illnesses or disabilitiesAre you currently taking any medication
If you have answered Yes to any of the above, please provide details in the box below

When did you last have a Tetanus immunisation

Equipment

I understand that I will have to provide my own clothing, waterproofs and footwear for the course. The Training Centre will provide boats and buoyancy aids free of charge for the duration of the course.

The Training centre will provide tea, coffee, juice and biscuits throughout the day but please bring your own packed lunch each day. There is a microwave and stove available for your use.

I give permission to the organisers and coaches of activities during the training period or event to administer any relevant treatment or medication to the above named participant when or if necessary.
Parental Consent:
In an emergency situation I authorise the organisers and coaches to take my son/daughter to hospital and give my full permission for any treatment required to be carried out in accordance with the hospital’s diagnosis. I understand that I shall be notified, as soon as possible, of the hospital visit and any treatment given by the hospital.

Please tell us anything else that you think is relevant.

I can swim 50 metres without a buoyancy aid? 


I consider that I am fit enough to undertake the above course and agree to the above  

Course Fees

I have sent a chequeI have sent payment by EBanking


Payment amount £ Payment date  


Electronic Banking: Nantwich & Border Counties Sailing Club, Barclays Bank Plc, Newcastle -under-Lyme. Sort Code 20-59-23   Account No. 30661333 Quote your name under “reference” Cheques are payalbe to N & B C S C please

Please check the box to agree and then click Send 

 

 

 

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