Surname: ________________________________
First Names: _________________________
Gender:
Male
D.O.B: __/__/____
UCLan Staff
£5
Employee Number: ____________________
Student
£5
UCLan Student Number: ________________
Child Over 8
£5
Female
OR NUS Card £5
General Public £10
(Children under 8 do not have to register & must be accompanied by an adult - they do not get a t-shirt)
T-shirt Size:
XS
S
Home Telephone: ________________________
M
L
XL
XXL
Mobile number: ______________________
Email Address: __________________________
Please read the following:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Do you have any medical conditions such as asthma, heart disease, epilepsy or diabetes?
Do you have any allergies that you are aware of?
Do you have chest pains brought on by physical activity?
Have you developed chest pains in the last month?
Have you on one or more occasions lost consciousness or fallen over as a
result of dizziness?
Do you have any bone or joint problems that could be aggravated by the proposed
physical activity?
Has the doctor ever recommended medication for your blood pressure
or heart condition?
Are you recovering from a recent operation or injury?
Are you aware, through your own experience or a doctor’s advice, of any other physical
reason that would prohibit you from exercising without medical supervision?
YES/NO
YES/NO
YES/NO
YES/NO
YES/NO
YES/NO
YES/NO
YES/NO
YES/NO
If you have answered yes to any of the above please give further details below:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
If you answer ‘yes’ to any of these questions, call your personal physician or healthcare provider
before doing any physical activity.
I have answered ‘yes’ to one or more questions and have been cleared by my personal
physician/health provider that I am safe to undertake exercise. (please tick)
If there are any changes in any of the above circumstances please inform us immediately!
Applications will only be accepted on the appropriate Registration Form and will be subject to any Special
Conditions set out on the Registration Form and the Arena’s Conditions of Use. The Arena’s Conditions of Use
are displayed in the Arena’s reception and available on request. Our agreement with you will incorporate
both sets of Conditions.
The Arena complies with the Data Protection Act 1998. The information you supply will be held by the
University so we can provide you with the best possible service. We may use this information for marketing
purposes.
So we can keep our records up to date please advise us of any changes.
I understand by signing this Registration Form that I agree to abide by the Special Conditions set out above
and the Arenas Conditions of Use. I have been given the opportunity to read the Arena’s Conditions of Use. In
addition I consent to the University holding information contained in this application form.
Signed: _____________________________________
Date: ________________________
Those under 18 years of age, I give consent for my son/daughter to participate in UCLan Color Run
Parent/Guardian Signature: __________________________
Date: ________________