MCSRD Form for Individuals

All fields marked * are required

Start Date of Canoe Trip*

Name*

Email*

Date of Birth* / /

Postcode*

Gender*MaleFemale

MOBILE phone number*

Please select your age group:*Under 1616 - 1718 or over

PLEASE NOTE!
1) If you are under 16 you can not consent to your own participation at WANT TO CANOE? and are therefore unable to complete this form - please seek advice at the main office OR CALL 01497 820604.
2) If you are aged 16 - 17 you must provide your parent/guardian details below and they will be contacted prior to your activity to confirm that consent is given for you to participate.

Car Registration Number (if parking at Want to Canoe?)

Name of person who made the booking*

Do you have any medical conditions and/or allergies of which we should be aware? (please don't hesitate to ask if you'd rather speak to a member of staff privately about this)

Do you, any member of your household/bubble and/or any member of your canoeing group have any Corona Virus symptoms?*YesNo

Do you agree to contact want to canoe? immediately should you, any member of your household/bubble and/or any member of your canoeing group develop Corona Virus symptoms prior to your canoeing trip and also up to four weeks after your canoeing trip?*YesNo

Please detail any other information that may be relevant to your participation in activities at Want to Canoe?

Are you a swimmer, non-swimmer or please give details…

Emergency contact details / Next of kin:

Name*

Telephone Number*

Relationship to you*

If you are aged 16 - 17 you must complete all questions on this page! Your parent/guardian will be contacted prior to your activity to confirm that consent is given for you to participate.

We occasionally film/take photographs for publicity purposes, do you agree to us using photos or footage that includes you?*YesNo

I understand that the activities I'm participating in will expose me to hazards and involve the risk of property damage, property loss, personal injury, illness and death. Whilst want to canoe? takes all reasonable steps to ensure my safety I understand they can not be held liable for my own actions, for which I must take responsibility, or for those of a third party. (if you answer NO you will not be permitted to participate in activities.)*YesNo

I have disclosed all relevant medical conditions on this form. Despite conditions disclosed I am sufficiently fit, able and competent to participate in the activities specified on booking.I have been able to read and agree to the want to canoe? RULES AND REGULATIONS, COUNTRYSIDE AND RIVER CODE OF CONDUCT and COVID-19 OPERATING PROCEDURES*.

You must answer YES to one of the questions on this page to be permitted to participate in activities*.I am aged 16 - 17 and confirm that all the information supplied herein is correct. In the event of an incident or accident, I agree to receiving first aid from a suitably qualified person and/or any medical or dental treatment which may be considered necessary by a registered medical practitioner.I am over the age of 18 and confirm that all the information supplied herein is correct. In the event of an incident or accident, I agree to receiving first aid from a suitably qualified person and/or any medical or dental treatment which may be considered necessary by a registered medical practitioner.

For the safety and health of the want to canoe? staff and instructor team during the Covid-19 pandemic it is not acceptable for anyone outside your booked and confirmed group to join you on the river in their own, hired or borrowed canoe, kayak, SUP or similar.
I/we confirm that all group members have been disclosed to want to canoe? on this and any other relevant MCSRD Form and that we will not be joined by anyone else during our activity.*YESNO

British Canoeing (the national governing body for canoeing in the UK) and [Want to Canoe?] would like to use your name, date of birth, postcode, gender and email address for internal reporting to monitor participation. Personal data will be used only in accordance with the Data Protection Act 1998 and current GDPR Legislation. Your contact details will not be passed to third parties. Tick here if you agree to your information being used in this way.YesTick to accept

Newsletter & Offers: We would love to keep you up-to-date from time to time with details of goods, services, offers and/or activities of British Canoeing & want to canoe? which may be of interest to you by contacting you by email. If you would like to receive the information described please tick here to subscribe.Yes Tick to subscribe

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