OFF-SITE ACTIVITY MEDICAL AND CONSENT FORM

This form must be completed and signed by parent or guardian if the participant is under 18 years old and by the participant if he/she is over 18 years. Please complete this form using capital letters and deleting as appropriate.

The Duke of Edinburgh’s International Award is a youth development programme. The Adventurous Journey is one of the four sections and seeks to improve participants with a unique, challenging and memorable experience. The
journey should be undertaken in a small team in an unfamiliar environment, requiring determination, physical effort and perseverance. Participants are required to plan and undertake their journeys, without outside assistance and
direct supervision. The expeditions take place under potentially unpredicted weather conditions and the overnight is in tents. They have to carry a rucksack that could weigh up to 15kg or more with all necessary equipment and food.
Expeditions and/or explorations last anywhere from two days to four days with the purposeful effort to be from 6 to 8 hours per day according to level.

Level of Adventurous Journey*

Participant's name*

First Last

Date of birth*

Address*

Street Address City ZIP / Postal Code

Telephone number*

Contact(s) for next of kin during period of activity/adventurous journey:

Name 1*

First Last

Telephone number*

Address is the same as participants

Yes

Use participant's address.

Address*

Street Address City ZIP / Postal Code

Name 2*

First Last

Address is the same as participants

Yes

Use participant's address.

Address*

Street Address City ZIP / Postal Code

Telephone number*

Please give details of any medical conditions*

e.g. diabetes, epilepsy etc. or allergies

Please give details of any current medical treatment, including medication.*

Date of last tetanus injection:*

Special dietary requirements:*

Can the participant swim?*

Not at all

less than 50 meters

more than 50 meters

Consent*

I acknowledge receipt of, and understand, the information regarding the proposed outdoor activity in Cyprus
and consent to participating.
I have ensured that he/she/I understand(s) that it is important for his/her/my safety and for the safety of the group that
any rules and instructions given by staff are obeyed.
I undertake to inform the Award Leader / Supervisor of any changes in the health of participant/my health prior to the
date of departure.
I am in agreement that those in charge may give permission for my son/my daughter/me to receive medical treatment
in an emergency

Relationship to participant*

+35722254612

OFF-SITE ACTIVITY MEDICAL AND CONSENT FORM

Contact(s) for next of kin during period of activity/adventurous journey:

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