searchtel 01904 500094 email@example.com
Please take the time to ensure that this information is accurate as we will use this information to book portions of your activity. Lost Earth Adventures cannot be held responsible for any problems that arise due to this form being completed incorrectly.
Please tell us your chosen activity:
Date of your chosen activity (dd/mm/yyyy):
Please give us the name of your group organiser (lead name):
Your first name:
Your middle names - If applicable:
Date of Birth (dd/mm/yyyy):
Mobile telephone number:
Confirm email address:
Street Name and Number:
Name of Emergency Contact:
Relationship of Emergency Contact to you:
Emergency Contact telephone number:
Please describe and detail any medical condition you have and any precautions you need to adhere to or dietary requirements (if none, write none):
If you are on or are required to take any medication please list the name of the medication you take, the required dosages and times it is needed to be taken (if none, write none):
Please tell us your weight (important):
Please tell us your height (important):
Please tell us your shoe size (important):
Optional: Additional Information:
How did you hear about us? ---Google or other search engineRecommendationLeaflet or brochurePosterAdvert in magazineThink AdventureArticle in the pressMet our team at an eventReferral from other websiteThrough an agentSocial mediaOther
By submitting this form you agree to the following 6 statements
1. You participate in the activities provided by Lost Earth Adventures at your own risk. If you feel any pain, dizziness or other problems you should inform your instructor immediately.
2. I understand that Lost Earth Adventures accepts no responsibility for loss, damage, or injury caused by participating in the activities provided by Lost Earth Adventures except where such loss, damage or injury occurred due to the negligence of Lost Earth Adventures.
3. I consent to receiving medical treatment that in the opinion of a qualified medical practitioner may be necessary.
4. I consent to undergoing First Aid treatment from a member of Lost Earth Adventures staff holding a First Aid Certificate if required.
5. I accept that there is an element of risk involved in the activities that Lost Earth Adventures provides.
6. By submitting this form you are hereby agreeing to the ʻTerms and Conditions of Courses Arranged by Lost Earth Adventures That Take Place in the United Kingdomʼ which is available to view on our website here: Terms and Conditions and confirm that you have read them. Please tick the box if you agree.
Mailing List If you would like to be sent exclusive deals and details of our new up and coming adventures, please tick this box to be included in our mailing list. We promise to never send you more than 12 emails a year.
If you have any trouble reading the Terms and Conditions or if there is anything about them that you do not understand then you must call us on 01904 500094 and we will be able to send you a copy or explain them to you in more detail. Please do not submit this form until you have read, understood and agreed to our Terms and Conditions.
THIS FORM WILL NOT HAVE SUBMITTED UNLESS YOU HAVE ANSWERED EVERY QUESTION ABOVE. YOU WILL RECEIVE A THANK YOU MESSAGE ONCE IT HAS SUBMITTED SUCCESSFULLY.
Thank you for choosing Lost Earth Adventures. We hope you will find your trip rewarding and fun.
Copyright ©2019 Lost Earth Adventures, All Rights Reserved. Lost Earth Adventures is a Limited Company Registered in England No. 7455734. VAT No. 234433135.