Tuition Health Declaration Form

Emergency Contact Details

I declare that...

  • I am in good health and physically fit enough to take poart in my chosen activity.
  • I have the following conditions that Derwent Water Marina staff should be aware of:

    (e.g. epilepsy, diabetes, heart condition, asthma)

  • I have the following recent / long term injuries that Derwent Water Marina staff should be aware of:
  • (e.g. back problems, muscle / nerve injuries or damage, recently healed breaks or dislocations)

    I consent to my photograph to be used in Derwent Water Marina publicity

    I consent to a video being made of me for training / tuition purposes

    I consent to my photograph being uploaded on to 'Derwent Water Marina' social media outlets for me / memebers of the public to view.

    I am happy for Derwent Water Marina to notify me of any offers

    Signed: Signature box needs to go here

    (Parent / Guardian must sign for under 18')

    N.B. Your personal data will only be used for the delivery of this session / course and will not be used for marketing unless you specify you would like us to contact you. We will not pass your data on to a 3rd party. Please see our provacy policy here.