Nature on Prescription - Registration
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Wilde Earth Journeys - Community Walks
Name *
Date of Birth
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Gender
Address
Email address
Telephone number
Method of contact if no phone or email
Emergency contact name
Emergency contact number
Name of GP surgery
List any medical conditions you feel we should know of, thank you
In the event of a medical emergency, do you take any prescribed medication that you feel we should know about. If so please list here, thank you
Describe any allergies you have.
Describe any dietary requirements you have.
If there is anything more you would like to share to ensure you have have the best experience 
Are you a carer?
Photography / Video Consent

We may take photographs and make videos and/or sound recordings throughout the duration of the project/activity, which may be displayed as part of an exhibition and used to promote the project/activity.  

• We may use these images in printed publications for promotional purposes.

• We may use these images to accompany our press releases, which may subsequently appear in the local or national media.

• We may use photograph(s) and any reproductions or adaptations of the photograph(s), videos or sound recordings for all general purposes in relation to Cinderford Artspace.

• We may use these images, film and recordings on our website and social media sites.

• We may use these images in promotional videos.

We will not include details or full names (which means first name and surname) of any person, in

an image or video, on our website, via social media or in any in printed publications, without seeking  your permission.

I give my permission  to take photographs, record soundtracks and videos which may be used as detailed above

 *
Required
Declaration

I declare that the information that I have provided is true and accurate to the best of my knowledge.

I understand that whilst every effort is made by personnel running events on behalf of the project to ensure safety during activities, I acknowledge that I am participating voluntarily and do so at my own risk.

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Required
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