Basic Information Name Address Mobile number Email Emergency Contact Details Emergency contact name Emergency contact number Medical Information Medical Information Image Consent I hereby give my permission for any video and audio footage recorded of me (‘my contribution’) to be edited and included in public video film(s) about LYC and Big Adventure for the resulting video(s) to be exploited in all media in all territories in perpetuity at the sole discretion of Lancashire Youth Challenge and Big Adventure without further reference to me. I give all consents that may be required. I confirm that I have understood and agree that no fees whatsoever will be payable to me. Signature Date Statement of Risk Statement of Risk: Outdoor and adventurous activities have an element of risk, which includes a danger of personal injury or death. It is important that participants are aware of, and accept, the elements of risk and the need to take responsibility for their own actions. I DECLARE THAT I AM MEDICALLY FIT TO UNDERTAKE ADVENTUROUS ACTIVITIES AND UNDERSTAND AND ACCEPT THE NORMAL RISK OF BEING IN AN OUTDOOR ENVIRONMENT Signature Date I consent to any emergency medical treatment that may be necessary whilst under the supervision of Big Adventure. Signature Date Data protection statement: Other than as specified above, the information that you give us here at Lancashire Youth Challenge will only be used to contact you about these photo(s)/film(s). We will not pass the details recorded on this form on to any other organisation without your permission. To pay the registration fee and upload your sponsorship money please go here.