Activity consent form

Activity consent form

Complete this pre-registration form before arriving at Dinton Activity Centre. It will make your check-in process quicker and easier. You won't be able to participate in any activities until a signed copy of the form is received.

Indicates mandatory fields

Activity consent form

Please complete this form and submit it prior to your activity day/first day of your course. Please note that you will not be able to participate in any activities until one completed consent form per participant has been received. 

Participant details - one per form.

 

Emergency contact - for duration of course

 

Medical conditions / injuries / illness

We kindly ask that any medication left in our care is clearly listed on the consent form, along with information on what it is for and when to be administered. Please also state clearly if medicines left at the centre must accompany the participant at all times (on land and water), or can be left at a central location within the centre. If the medication must stay with the participant at all times (on land and water), you must provide a dry pack for the medication.

Does the participant have any medical conditions/ injuries/ illness that we should know about?:

Allergies / food intolerance's

Does the participant have any allergies or allergic to food/medication which we should know about?
Does the participant take any medication which we should know about?

Additional needs

 
If applicable, please provide details of any additional needs.
If you require any additional adjustments to be made we must be contacted prior to booking on 0118 934 4424.  
If you wish to opt in to receive further information about Dinton Activity Centre or Countryside Service, tick the box

Photography Consent

 

We may use your use your photograph, film and words to publicise events, in newspaper articles, magazines and other media such as websites and Intranets, social media, information leaflets, marketing materials such as posters and displays, electronic newsletters and presentations

 

You can contact Dinton Activity Centre at any point and ask us not to use your photograph, film or words. 

 
 
 
Read our terms and conditions, below.  
 
Terms and Conditions (PDF document)  
 
Terms and conditions:
Declaration:
 
You do have the right to request that you sign a paper copy instead, however by ticking this box you are waiving that right. You have the right to submit a written request to obtain a paper copy of the electronic form and electronic signature.  
 

Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. Please ensure  you update us of any change to your contact details so we can get in touch with any changes, if necessary.