Details of your activity with able2sail

  Have you been offered a Date and Time to sail with able2sail? * Yes No

       If Yes, please indicate below.

  Date Of Activity  -- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 ---- May June July Aug Sept Oct ---- 2010 2011

  Time Of Sail        Please Select Morning Sail Afternoon Sail

  Have you ever sailed with able2sail before? * Yes No

        If Yes, please give details below.

Personal Information

  Title*            Select Mr. Miss Mrs. Ms. Dr.

  Surname*    

  Forename*  

  Age*           

  Please indicate below, the approx size of sailing suit you require*
                   
                     Please Select Adult XXL Adult XL Adult Large Adult Medium Adult Small Child Large Child Medium Child Small

  Address*

  Contact No*

  Mobile No*  

  Email*          

  Which of the following are you?*

     Please select box/s below, that apply to you.

         Client
         Parent
         Carer
         Sibling
         Other

      If you selected Other, please give details below.

                        

GP Details/Medical Information

  GP Name*

  GP Address*
                   

  Are you disabled?* Yes No

               If Yes, please give details of nature of disability below

.                   

  Are you a wheelchair user ?* Yes No

  Do you require to be hoisted aboard the yacht?* Yes No

  Are you currently taking any medication?* Yes No

             If Yes, please give details of any medication below.

                   

  Do you have any allergies (Inc. Food)?* Yes No

            If Yes, please give details below.

                   

  Please give details of any triggers that may cause difficulties below.

                   

Next Of Kin / Shore Contact Details

  Name*          

  Address*
                        

  Contact No*  

  Mobile No*   

Photo permission

 Thank you for agreeing for yourself and/or, child/ children/ young person(s) to take part in recording the event for future use by able2sail, to promote  work of able2sail. The photographs and videos are used at private, ticketed able2sail events and to send to companies and some individuals to help raise  funds for able2sail. Some of our photographs may be used for for “public purposes” – for example, but not exclusively, for newspaper articles, posters and leaflets.
Your assent on this form gives us permission to use video footage and photographs of yourself and/or, the child/ children/ young person(s) noted on this form for profile/ fundraising for able2sail, as well as the able2sail website, but not for commercial exploitation.
  Permission on this form is for perpetuity and is on the basis of no fee being payable to you and/or the child/ children/ young person(s) on whose behalf you are completing this form, now or at any point in the future.

Please complete the below form to confirm, on the above basis

  Date* -- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 ---- Jan Feb March April May June July Aug Sept Oct Nov Dec ---- 2010 2011

 If completing this form or behalf of someone else please also complete section below.

  Their Full Name  

  Your Full Name  

  Capacity of Care 

  Your Contact No

If you have any queries regarding photo permission or any other section of this form please contact us at:

able2sail

26 Alyth Crescent,

Glasgow

G71

Contact No: 07737028437

Email: contactus@able2sail.org.uk

Additional Information

Please use the space below, to tell us of anything else you feel may be relevant.

                              

Declaration

Date* -- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 ---- Jan Feb March April May June July Aug Sept Oct Nov Dec ---- 2010 2011

 If you have filled out this form behalf of someone, please indicate in which capacity you have given the consent ie, parent, guardian or carer.

Capacity Of Care

 Submit Information

 Once you have completed all information please click below and your details will be submitted to Able2Sail.