Yeovil Abseil Challenge

Yeovil Abseil Challenge is taking place on Sunday 22 May 2016 at Yeovil Hospital from 10am.

Challenge yourself to our 100ft abseil from the roof of Yeovil Hospital and raise money for your chosen area of Yeovil Hospital. You will be given professional instruction and all the equipment you require to complete the 100ft abseil.

The events is open to everyone over the age of 12. If you are under 18, a parents consent must be given and a guardian must be present on the day of the abseil.

Registration fee is £15 and a minimum sponsorship of £75 is required. On receipt of the completed application form we shall send you a confirmation letter with the time you are booked in for the abseil and an abseil pack with all the information you will need to complete your abseil, including a copy of the sponsor form.

For more information please contact Sarah Cherry on 01935 383020 or [email protected]

If you would like to register for this event please fill out the below form.

Title:

First name:

Surname:

Address:

Postcode:

DOB:

Age:

Phone number:

Mobile:

Email:

Emergency contact name:

Emergency contact number:

Do you have any special medical conditions?

If you want to support a particular department/area within the hospital please let us know (you can leave this blank if you prefer)

Please tell us if you have a special reason for taking part:

Please tick here if you pledge to raise £125 in order to receive your free t-shirt  Yes

What t-shirt size do you require?  Small Medium Large Extra-large

Do you need a child's t-shirt or an adult's t-shirt?  Child Adult

Can we use your story to publicise our event?  Yes No

How did you hear about the event?

Please select the chosen method of payment:

 Paying by cheque Bank transfer

All cheques are made payable to Yeovil District Hospital. Please ensure the name of the participant is on the back of the cheque with the reference Abseil 2016.

Reference: Abseil 2016 (this is mandatory to ensure we are able to identify your payment).

Account number: 70177287
Sort code: 60 24 37

I agree to take part in this abseil at my own risk and understand that Yeovil Hospital Charity, Yeovil District Hospital and ISCA Outdoor will not be responsible for any loss, damage, injury or death resulting from this event.

The chances of a serious injury are extremely low but minor injuries (bruises, bumps and grazes) are a possible result of taking part in an adventurous activity.

I understand that all the appropriate licences and insurances relating to this activity are held by ISCA Outdoor and that all precautions have been taken to eliminate or reduce the risk of injury to myself while taking part in the abseil.

I am over 18 and I am not aware of any medical reason why I should not take part in this event, and I agree to tell the organisers in advance of the abseil if one should come to light between now and the event.

I understand that if Yeovil hospital Charity or their agents feels that the weather conditions on the day are unsuitable for this type of activity then the event will be postponed.

Please tick the box below if you have read and agreed to all of the above.

 I agree to the above statement

If you are aged 18 or under a parent or guardian must be present on the day to sign a consent form.

Yeovil Hospital Charity would like to keep you informed of events that may be of interest to you and send you details about our work. If you would prefer us not to keep your details for this purpose please  tick here.

By taking part all participants agree that they are happy for their names and any footage or photographs taken during this event can be used to publicise Yeovil Abseil Challenge and Yeovil Hospital generally, including television broadcasts.