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Name (Mr,Mrs,Ms,Miss)____________________________________
Address__________________________________________________
__________________________________________________
Postcode_________________
Tel:(Day)_______________________(Eve)____________________
Course Applied For_______________________________________
Give details of relavent
boating experience.______________________________________
________________________________________________________
________________________________________________________
DECLARATION:I declare to the best of my knowledge, I do not suffer from epilepsy, any disability, dizzy spells, angina,heart or other medical conditions that would exclude me from participating in this course. I declare I am medically fit to undertake this course. Any doubts consult your doctor.
Details of medication being taken.
__________________________________________________________
Signature_______________________________________
Date____________________
Emergency Contact & Number
Name__________________________
Telephone___________________________
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