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MEMBERSHIP CONSENT FORM

First name*

Last name*

Email*

Phone*

Birthday

Day

Month

Year

Address*

Date

Day

Month

Year

EMERGENCY CONTACT DETAILS

Name and relationship to you/your child*

Email*

Phone*

MEDICAL HISTORY

Name

History of heart problems (i.e. chest pains, heart murmur, stroke)

Diabetes

Asthma, breathing or lung problems

Allergies

Cancer

Seizures, seizure medications, neurological problems or dizziness

High blood Pressure

Back problems, joint or muscle disorder

Recent Surgery

Hernia or any other condition that might be aggravated by exercise

Doctors advice not to exercise

History of high Cholesterol

Family history or coronary heart disease

Do you/your child suffer from any medical conditions/ allergies that we should be aware of?*

Yes

No

Are there any activities in which you/your child can not participate?*

Yes

No

If YES, please state them below:

Are you on medication, if YES please state*

If relevant, have you been pregnant in the last 3 months?

Do you give permission for you/ the named child to be assisted with first aid if necessary during skating sessions*

Yes

No

I understand roller skating can be a dangerous sport and Gbendle Roller Skating takes no responsibility for injury caused to participants at sessions. This includes, but is not subject to: breaks, fractures, concussions, sprains and any pre-existing conditions that are exacerbated by partaking in the sport.

PHOTOGRAPHY & SOCIAL MEDIA

Name

Do you give permission for you/ the named child to be photographed during skating sessions? Please note and understand that these images may be used on social media platforms for business purposes only*

Yes

No

Contact

I consent to being contacted by email for updates and information that Gbendle Roller Skating deems necessary.*

Yes

No

If you need to contact us please don’t hesitate to email gbendlerollerskating@gmail.com or send a message through the GBendle Roller Skating page on Facebook

Any information you provide on the forms will be stored confidentially and retained in line with current GDPR. You will have the right to request this information at any time and to have it removed permanently from storage.

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