Calvert Lakes

Compulsory Guest Information and Consent Form

Strictly Private & Confidential
It is vital that we receive completed and signed forms at least two weeks prior to arrival.  This information is a compulsory health and safety requirement for your visit.  We require completed forms from everyone attending.  If you are unsure of / or do not wish to share any details, please insert N/A into the text box.

Type a date, for example 25 December 1990, or choose one from the calendar.
Which gender identity do you identify with?
Other
What are your preferred pronoun/s?
Please tick the box that most closely describes your / the participant's ethnicity.
Other
Name
Address
Phone No
Email
Relationship
Name
Address
Phone No
Please note that this information is required for some of our activities, to ensure participant safety on bikes, during climbing activities and some other activities.
Please note that this information is required for some of our activities, to ensure participant safety on bikes, during climbing activities and some other activities.
We understand that everyone is an individual but, so that we can plan for your visit, please indicate the most relevant disability, impairment or condition that applies to you. Please select all that apply.
Please provide us with details of your disability/impairment or condition and how it impacts your day-to-day functioning.
Please select all that apply.
What type of wheelchair will you be bringing to Calvert Lakes? Please select all that apply.
My wheelchair can be clamped into a minibus and I will travel in it.
Transfer Details - Please select all that apply
Please select your specific equipment requests. Please note that some items are limited and are allocated on a first come first served basis. You can select more than one option as required.
Other Equipment Requests
Do you have any other medical conditions e.g. asthma, behavioural issues, diabetes, heart condition, back injury, contagious diseases, allergies? If yes, you will be asked for more details in the next question.
Please provide details below
Do you take any prescription medication? If yes, you will be asked for more details in the next question.
Please list all prescription medication (including dosage) you will be taking or bringing to Calvert Lakes.

Please ensure that all medication is in date, brought in original packaging and that you have enough for the duration of your stay.  If you use an asthma inhaler or adrenaline auto-injector, please bring at least one spare.

Do you have epilepsy? If yes, you will be asked for more details in the next question.
Please give details below including severity, frequency and if rescue medication is needed.
Please select all that apply.
Please use this space to detail any other information we may need to know.

Privacy
Your privacy is important to us. 
We will use this information to manage your health and safety while you participate in a course of activities with the Lake District Calvert Trust. Your information will be treated confidentially and will only be shared as required to organise and manage your visit.  This could include being shared with the leader of your visit, the person who has booked your stay or, in the event of a medical emergency, this information may be shared with the emergency services.

The Lake District Calvert Trust may also produce anonymised statistical data to report on meeting our equality targets and charitable objectives or to support research.  Our full Privacy Policy can be found on our website at Privacy Policy

We would like to keep you informed about the charity and the services we provide. If you would like to receive this information please indicate below how you would like to be contacted. You can opt out at any time by contacting us.
Please indicate below your participant consent across select media to promote the work of the charity. We will never include your name without additional consent from you

Confirmation of Consent
To be signed by participant or carer / advocate (if under 18 by a parent or guardian) or by a teacher / school representative for an organised school visit (where the school has already obtained consent).
The above information is, to the best of my knowledge, correct.  I undertake to inform the Calvert Trust of any relevant changes in Medical Circumstances and I give my consent for Emergency Medical Treatment, including anaesthetic, as considered necessary by the Medical Authorities.  I am aware of the nature of the organisation, that there is an element of risk in outdoor activities and I, nevertheless, voluntarily accept the risks involved.

Print Name

Signature pad. Draw your signature with a mouse, finger or stylus.

If, for any reason, you are unable to provide a digital signature on this document—for instance, if you are using assistive technology such as a screen reader—please indicate your agreement by selecting the checkbox in lieu of a signature.
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