Disclaimer Form

Disclaimer Form

Full Name:
Date of birth:
Event: / Mayfair Power and Tower Race – Friday May 26th 2017
Home Address:
Home Tel No: / Mobile No:
T Shirt size / S M L XL
Next of Kin: / Tel No:
Any known allergies:
Any current medication:

I am physically fit and understand the risks involved in competing in the event. I understand that this event is physically demanding and I am not aware of any medical reasons for me not competing.

I do not suffer from a heart condition or chest pain brought on by physical exertion or suffer from dizziness, vertigo or loss of consciousness brought on by physical exertion or have diagnosed with osteoporosis or osteoarthritis.

I have never taken medication for blood pressure or a heart condition or suffer from high blood pressure or suffer from back pain brought on by exercise.

I am aware that it is my responsibility to ensure that my clothing and footwear is suitable for the event, and that I should carry and drink plenty of fluids throughout the event. It is also my responsibility to ensure that I use suitable protection against the effects of sun and all other elements. I accept responsibility for organising my own insurance, ensuring my own safety, and obtaining any necessary permission required for the event.

I accept that the DM Thomas Foundation for Young People, the charity which I am supporting, accepts no liability whatsoever for any injuries, financial losses or any consequential losses.

Signed: …………………………………………. Date: …………………….

Please sign and return to: DM Thomas Foundation for Young People,
179 – 199 Holland Park Avenue, London W11 4UL

Sponsorship money raised via the Mayfair Power & Tower Race for Galvin’s Chance should be made payable to

DM Thomas Foundation for Young People
Registered Charity No. 1084220 (England & Wales) SC038995 (Scotland)