CONSENT FORM - ADULT

Please fill out the following form in order that you can participate in our activities.

Your First Name

Your Date of Birth

Your Last Name

Your Gender

Your Ethnic Origin

Your Email Address

Your Address

Your Phone Number

Emergency Contact Name

Emergency Contact Telephone

Emergency Contact Mobile

Do you suffer from a medical condition, illness, or injury?

Yes

Do you suffer from any allergies?

Yes

Do you take any medication?

Yes

Do you have a disability?

Yes

Do you have any special requirements that we should know about?

Yes

If you answered YES to any question, please provide further details.

I give consent for photography and/or video footage to be used on Sporting PB's website & social media accounts.

I give my consent that if an emergency medical situation arises, the organisation/club may act in administration of first aid and/or other medical treatment that in the opinion of the member of staff is neccessary.

I can confirm all details within this form are correct.

Date Form Completed

Thanks for submitting!

CONTACT

Sporting PB Ltd

20 Victoria Walk

Hixon, Stafford

ST18 0RH

T: 07772 175336

E: ollie.crooks@sportingpb.co.uk

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