Booking Form

* (denotes required field)

First Name:*

Last Name:*

E-Mail Address:*

Address1*

Address2

Town / City*

Post Code*

Region

Country

Mobile Phone Number*

Your Organisation (if any)

Course*

Select: Wild Mindfulness: 23rd - 28th June 2013

Do you have any special dietary requirements?*

Yes
No

If 'yes' please give details:

Do you have any medical conditions?*

Yes
No

If 'yes' please give details:

Do you take any form of medication?*

Yes
No

If 'yes' please give details:

Gender*

Female
Male

Date of Birth*

Next of Kin

Name*

Phone Number*

Disclaimer

By ticking this box I confirm that I accept David Key's Terms & Conditions. and reiterate that:

• I am physically and psychologically fit for the course I have chosen and I have disclosed any medical conditions that may effect my safety, or the safety of the group, or the group leader(s);
• I appreciate that my course may be hazardous by its nature and I accept that a certain element of risk is inherent in outdoor activities;
• I understand that if I choose not to take the safety advice given to me by the course leader(s), I am personally liable for the outcome;
• I have taken out appropriate insurance relevant to the course I have chosen.

I accept*