INDIVIDUAL PLAYER REGISTRATION FORM:
Team Name:
Team Captain:
Full Name:
Date of Birth:
Address:
Email Address:
Telephone No:
Emergency Contact Name and Telephone number:
Y
N
Y
N
Do you suffer from any heart conditions?
Do you suffer from Epilepsy / seizures?
Have you suffered from back or Neck
Do you suffer from Diabetes?
problems in the last 2 years?
Have you suffered from dizziness of fainting in
Are you Asthmatic?
the last 2 years?
Do you suffer from any chest or breathing
Do you wear glasses or contact lenses?
problems?
Do you suffer from high blood pressure?
Do you have any allergies / hay fever?
Have you suffered from any bone or ligament
Do you suffer from Migraines / headaches?
injury in the last 2 years?
Are you currently taking any prescribed
Do you have any allergies to medications?
medication?
If you have answered YES to any of the above or feel we should be aware of any other medical conditions please give
further details below:
I agree to be in any photography taken during the event
to be being used for promotional purposes:
I would like to receive the Hobsons email newsletter:
Y/ N
Y/ N
Declaration:
I understand and I am aware that strength, flexibility and aerobic exercise are potentially hazardous activities. I also
understand that exercise and fitness activities involve a risk of injury and even death, and that I am participating in
these activities and using equipment and facilities with the knowledge of the dangers involved. I hereby agree to
expressly assume and accept all and any risks on injury or death. I also hereby agree to the disclosure of this
information to a member of the emergency services and or a first aid qualified person for treatment purposes only.
I am aware that I have the right to request advice from any of the event staff at any time, in relation to the activities
and exercise being undertaken and, but not exclusively, their suitability for me, with particular regard to my health
and clothing. If I choose not to take advice, or to disregard any advice so given, I do so voluntarily and accept liability
for all resulting injuries or damage.
I hereby declare that the information given is full and true to the best of my knowledge. I do hereby declare myself
to be physically sound and suffering from no condition, impairment, disease or infirmity or other illness (other than
those declared on the attached medical questionnaire) that would prevent my participation or use of equipment or
facilities except as herein stated. I acknowledge that I assume all responsibility for my participation and activities.
Print Full Name:
Date:
Signed:
Contact:
Patrick Cudmore Hobsons Brewery
Tel: 01299 270837
Email: [email protected]