COVID-19 and Staying Well

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Health and Emergency Contact Form

This form must be completed by:

All adults (18 years old or over) participating in or working on (paid or voluntary) activities run by Heathery Heights.
Parent / guardian / legally appointed responsible adult of those under the age of 18 who are participating in activities run by Heathery Heights.

Your / The Participant's Details

First Name

Surname

Date of Birth

Full Address including postcode

Mobile Number

Email Address

Event / Activity Details

Name of Lead Contact/Organiser:
(please provide us with the full name of the person who booked this excursion/activity)Name/Location of Activity Booked:Date of Excursion/Activity:
(please provide us with the date your are participating and note that this form must be completed no more than 48 hours before that date)

Emergency Contact 1

Name of contact:Phone Number of contact:Relationship to participant:
(How do they know the participant?)

Emergency Contact 2

Name of contact:Phone Number of contact:Relationship to participant:
(How do they know the participant?)

Health Checklist

Allergies

Do you/the participant have any known allergies?Yes (please give details below)
No

Medical Conditions

Do you / the participant have any medical conditions/illnesses/disabilities or other special requirements that are relevant to this event/activity?
Yes (please give details below)
No

Medication

Please include any medication you or the participant are taking.
(Check No if you are not any any medication).
Yes (please give details below)
No

Medical Treatment

Are you / the participant currently receiving any medical treatment?
Yes (please give details below)
No

Dietary Preferences (e.g. vegan, gluten free):

Consent for Photography

We love to capture the beautiful moments and wonderful scenery while we are out on activities with clients. Please tick this box to let us know that you are happy for Heathery Heights to take photos and video footage on the day, which may be used in future marketing material.
I consent

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Coronavirus & other respiratory infections

‍You/the participant agree to adhere to current guidelines, look after yourself and others and maintain social distancing measures if required during an activity. Especially remember to maintain social distancing if you have recently finished a period of isolation as some people may be infectious for up to 10 days.

I agree.

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Additional Information

Please ensure all details are up-to-date for the day of the activity.

Where possible, please submit the completed form electronically 48 hours prior to the booking. Any changes must be notified on the day.

Heathery Heights Health forms are deleted regularly (on at least a monthly basis).

If you have booked our collaborative Walk, Forage, Swim experience please complete the Swim Questionnaire to participate in the Wild Swimming activity. Information you give on the Swim Questionnaire is collected by your wild swim instructor, Swim Dan the Merman, for your safety, and is collected under their own company policies.

For more information on our Privacy Policy please click this link: privacy-policy

Thank you! Your submission has been received!

Oops! Something went wrong while submitting the form.

Printable Health Form

We try to run our business in an environmentally friendly way, so we have forms available online, causing little to no paper waste. However if you need or would prefer to print the above form, please print, fill it by hand and bring it with you on the day.

A printable PDF of the above form can be found here.

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