Emergency Contact - Family member to be contacted in case of accident/emergency.

Medical Information - please declare any previous or current injuries/conditions relevant to the activities being undertaken. Please include any illness, allergy or disability and list any medication being taken, or state NONE.

Please summarise any experience in the activities to be undertaken. Include, number of years & level of activity.If no previous experience please state NONE.

Please add any more coments below:

Please state if you require us to supply either of the following:

Please make all Cheques payable to: Ian Hey

Post to:Tan Yr Allt, Fachwen, Gwynedd, LL55 3HB

For full booking, payment & cancellation conditions please see page 2 of the booking form. For courses booked more than 30 days in advance a deposit of 50% of the course fee is required to secure the booking. The balance is due 30 days before the course start date. For courses booked less than 30 days in advance full payment is required with the booking.

I recognise that climbing, hill walking and mountaineering are activities with a danger of personal injury or death. I accept these risks and understand that they can never be completely eliminated. I agree to abide by instructions and decisions made by Climb-Mountains and its instructors regarding the safety of myself and others on the course. I declare all the information on this form to be accurate.

Date: Saturday, 19th May 2012