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COURSE REGISTRATION & MEDICAL FORM

    Course Name

    Start date

    Student's Personal Details

    Your Name (required)

    Date of Birth (required)

    Your Home address (required)

    Your Email (required)

    Phone Numbers

    Emergency Contact Personal Details

    (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. This information will be only shared with the organisers and coaches at training and events.
    For example asthma, heart conditions, epilepsy etc.

    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

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