Address:

Emergency contact details:-
Name:

Relationship:

Address:

Medical Declaration: Please advise (in confidence) of any known medical history/problems, which are likely to affect your physical welfare during the course; I declare that to the best of my knowledge, I am not suffering from:

• Asthma or Bronchitis Yes / No             
• Diabetes Yes / No
• Epilepsy Yes / No              
• Fits, Fainting or Blackouts Yes / No
• Heart Condition Yes / No             
• Severe Headaches Yes / No
• Are you receiving any medication Yes / No             
• Allergies to any known medication Yes / No
• Are you suffering from any injury Yes / No
• Any other medical condition Yes / No            
  

If you have answered Yes to any of these questions, please provide details:

It is your responsibility to make known any potential medical conditions that may affect your own personal safety during the activities associated with the course. The above list above is not exhaustive.

Declaration: :  I certify on behalf of all those named on this form, by whom I am authorised to make this booking, I/we have disclosed any known medical history/problems that are likely to affect our physical welfare during the course and that I/we can swim 50 metres and am willing to comply with all safety requirements.
 
*For the sea survival course I/we agree to partake in a practical liferaft swimming pool session as part of the course.  This involves some physical exertion in the deep end of the swimming pool, while wearing a life jacket.  I/we are aware of the potential danger of using live flares during a demonstration and I/we do so at our own risk. I have read the terms and conditions and I am/we are fit and willing to participate in the course/s.

Signed:.…………………………………….Print

Name:.………………………………..Date:…………….

Please complete & return this form with the course fee thank you to: 

Poole Harbour Sea Survival Ltd

95  Pilsdon Dr,
Canford Heath,
Poole,
Dorset
BH17 9HT

Cheques payable to:  PHSS

or E-payment to: (Alliance & Leicester) PHSS  Sort Code 720000 Account 02732483