Events

Rugby Course Booking Form

Rugby Course | 31 July to 3 August 2023 | Ages 9-13 *

Residential £480
Non-Residential £410
Non-Residential with evening meal £435

Child's Name *

First

Last

Child's Date of Birth *//

Child's Age (at time of course) *

Child's Gender *

Female
Male

Parent's Title *

Parent's Name *

First

Last

Parent's Email *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Contact Phone Numbers (during Rugby Course): Mobile *

Contact Phone Numbers (during Rugby Course): Home *

Accommodation

Please indicate the name of one person who your child WOULD like to share a dormitory with (must be of the same gender). We will try our best to accommodate your request

Is there anyone that your child would NOT like to share dormitory with?

Name of Rugby Club or School *

Rugby Level

The players will be assessed at the start of the week and will be put into groups according to ability, age and social requirements.

Select your child’s rugby level *

Rugby - How many hours training undertaken per week?

Is your child is able to swim 50m comfortably? *

Yes
No

Is your child water confident? *

Yes
No

Medical Information

Doctors Name *

Doctors Phone Number *

Doctors Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Health condition(s) or hospital treatment (in the last 2 years) that may affect performance

Does your child suffer from the following conditions?

Asthma
Eczema

I can confirm that my child’s asthma is medically controlled and has stabilised and that he/she is not attending the above course contrary to medical advice

Yes

Allergies

Please detail substances including drugs, foodstuff and other substances to which your child has suffered an allergic reaction to:

If other, please specify

Please list any Medication taken

Dietary Requirements

Please provide details of your dietary requirement

Kit Sizing - Each child shall be given some kit, please confirm the size required: *

Marketing

How did you hear about the Mount Kelly Rugby Course? *

If you used Google to find our about this course, what did you type in?

If other, please specify

Would you like us to post you a Mount Kelly school prospectus pack? *

Yes
No

Do you give your consent to be contacted for marketing purposes? For example to notify you of future Rugby Course dates? *

Yes
No

Do you give consent for photography and filming of your child for rugby technique evaluation and for Mount Kelly marketing purposes? *

Yes
No

Activity Consent - I give consent for my child to participate in the following Rugby Course activities: swimming, ball sports, dodgeball, disco dancing, gymnasium - including use of rowing machines, cycling machines, light kettle bells and TRX (Total Body Resistance Exercise) and a short walk into Tavistock town to visit the shops.

Yes

Simply Outdoors and Trips

Your child has the option to take part in high ropes at the on-site outdoor adventure centre, Simply Outdoors. High ropes is an activity with a danger of personal injury or death. Participants in this activity should be aware of and accept these risks and be responsible for their own actions.

I do give my consent for my child to participate in the following activities: *

High Ropes
Surfing
I do NOT consent

Please state any other information or circumstances that may be relevant to your child's stay at Mount Kelly for the Rugby Course

Declaration

Mount Kelly or Simply Outdoors will not share any information or data collected with any third parties. In my opinion, my child is fit and able to take part in the Rugby Course activities. I give my consent to using over the counter products if required such as paracetamol, Strepsils, antihistamine or cough linctus, administered by the Rugby Course Matron or First Aiders. I understand in an emergency every effort will be made to obtain consent for treatment, operation or anaesthetic, but if this proves impossible, I authorise the Head Coach, Rugby Course Matron or Simply Outdoors staff to act in loco-parentis. A copy of the Mount Kelly and Simply Outdoors current Certificate of Public Liability Insurance can be provided upon request. Either company cannot accept liability arising from circumstances undisclosed in this Consent Form.

I believe that the information given is correct to the best of my knowledge. *