Youth Club Booking Form

All participants of Provela Academy courses and activities are required to provide next of kin contact details and a medical declaration, prior to starting their course. In the case of under 18’s, forms should be signed by a parent or guardian.

Start/ First Date

Finish/ Departure Date

Participant Details:

Title

First Name

Surname

Contact Number

Date of Birth

Postcode

Address

Next of Kin Details:

Name

Relationship to Participant

Emergency Contact Number

Medical Details:

Please answer the following questions but be assured that answering “Yes” will not necessarily prevent you from taking a full part in your chosen course.

Do you suffer from any of the following conditions?

Epilepsy, Giddy spells, Asthma, Diabetes, Angina, or other heart condition? Back or neck problems? Are you currently taking any medication? Do you have any disability or concerns relating to your health during this course? Can you swim more than 50m unaided?

Do you have any current medical condition not shown above? If so, please state below.

Confim:

MEDICAL DECLARATION

I declare that the responses I have provided above are correct to the best of my knowledge and I know no reason related to my health and well-being that will prevent me from undertaking this course. I will inform the Instructor immediately should I have any difficulties during the course.

PHOTOGRAPHY CONSENT

I give consent for any photographs taken to be used for future marketing.

TERMS AND CONDITIONS & PRIVACY POLICY

I have read and agree to the Provela’s Terms and Conditions. I also consent to the above details being used to contact me. For RYA courses names and addresses of candidates will be shared with the RYA for the purposes of registering your certificate. For full details please visit our website.

START & END DATES

By writing a Start and Finish Date for Youth Camp I understand that for the duration of the stated time this Information shall be used and understood by Provela Academy to be correct. Should this information change within the dates stated I shall inform Provela Academy as soon as possible. If I do not inform Provela Academy of any changes I understand that they are not liable.