Online Entry

Training 2017

To reserve you place please complete the form below.
Course
First Name
Surname
Gender
Date of Birth
Address
Town
County
Post Code
Email
Telephone
Mobile


Emergency Contact Details

Contact Name
Relationship to Helm
Home Telephone
Work Telephone
Mobile Number
Doctors Name
Doctors Telephone


Medical Declaration

Have you suffered from any of the following


Asthma or Bronchitis

Heart Conditions

Fits/ Fainting or Blackouts

Severe Headaches

Diabetes

Travel Sickness

Allergies to medication

Any allergies

Other illness or disabilities


Please provide details



Date of last tetanus vaccination :

Please list any current medication here :



Please list any injuries that may be relevant to your participation in this event



Declaration

I can confirm that I have read the course description. (If you are unsure please

contact the Training Principal before confirming your booking)

I confirm the participant is physically fit to undertake the course booked; that I

have reported any relevant medical problems and that I will notify you if any

circumstances change prior to arrival.

I agree to be bound by the rules and bylaws of Llyn Brenig Sailing Club as

published elsewhere on this web site.

During the event I will hold a valid and current 3rd party liability insurance of at

least £2 million pounds (if sailing my own boat).



I accept the above :