EmailMe Form - Client Application Form

Please indicate date of activity *

DD / MM / YYYY

Please select time of activity

Which of the following does this application form refer to *

Client

Other

If other, please specify in what capacity

Personal Information

Name *

First Last

Date of Birth *

Please indicate approximate size of sail suit you will require *

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Contact No *

Email *

GP Details

GP Name *

First Last

GP telephone number *

Town GP is based *

Disabled *

Yes

No

Wheelchair user? *

Yes

No

Do you require to be hoisted aboard the yacht? *

Yes

No

Nature of disability / medical needs including medication, allergies and triggers which may cause difficulty *

Next of Kin/ Shore contact details (2 persons required)

Name 1 *

First Last

Telephone Number *

Mobile

Name 2 *

First Last

Telephone Number *

Mobile

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

Name

First Last

Relationship to client

Telephone Number

By ticking yes I consent to the above photo permissions

Yes

No