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REGISTRATION
Registration

Registration Details

Program registration

Participant details

Responsible adult details

Contact address *
Contact address
City
State/Province
Zip/Postal
Country

In case of emergency

Address *
Address
City
State/Province
Zip/Postal
Country
Level of english *

Medical information

Do you suffer from any of the following conditions?
Epilepsy yes/no? *
Do you suffer from any other condition requiring that ActiveEarth/EasyDay should be aware of including previ- ous injuries, medical treatment and medication? *
Are you allergic or sensitive to any medication (e.g. Penicillin), insect bites or food? *
Are you taking any form of medication on a regular basis? *

Please ensure that you have adequate supplies of medication for your entire visit!

To the best of your knowledge, have you been in contact with any contagious or infectious diseases, or suffered any recent condition that may become infectious or contagious? *
Do you have any special dietary requirements? *
Privacy *

DECLARATION

  • I have read and understand the Terms and Conditions for Participation and accept them as contents of this contract
  • Besides a great experience, I am fully aware that other physical and emotional risks may be involved, such as transportation, rock fall, unpredictable weather conditions, uneven and slippery ground, hydrological features and other events out of the organisers direct control
  • I am in good health and am physically able to participate in adventurous outdoor activities
  • In the case of an emergency I agree to being given any medical, surgical or dental treatment, including general anaesthetic and blood transfusion, as considered necessary by the medical authorities present
  • I declare the above information is correct. I will ensure that any change to my circumstances, which could affect my participation in activities (e.g. recent medication or injury), will be notified to the organisers prior to the visit
  • I permit the organisers to use photos and videos taken on the programme for their promotional materials, such as websites, brochures etc.

Pont de Valenti Association Registration