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Individual Booking Form
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Activity & Location
eg, Improver in Spain, or Indoor in UK
Medical Conditions / Allergies / Disabilities / Recent accidents/injuries
Emergency Contact Phone Number
Relationship to you
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For more than one day, please provide the start and end date, inclusive. NOTE: For Spain, dates are during the season of 20th November 2015 - 21st February 2016
Contact Phone Number
Other Phone Number
Date of Birth
Medication you are taking regularly / at the moment
Travel details... For Spain
Outbound Flight No.
Return Flight No.
Flight Arrival Date
Flight Departure Date
Flight Arrival Time
Flight Departure Time
I agree to the following payment terms:
Deposit of 20% of total cost upon booking and final balance payable at least 21days prior to commencing course.
If booking less than 30 days before the course date, full payment is required.
Payment details will provided by email following receipt of this form.
In consideration of ‘climbcostablanca’ allowing me to take part in and engage in any adventure activity, I hereby acknowledge and declare as follows:
I confirm that I am over the age of 18 (if under 18 you must be accompanied by a parent/guardian at all times and they sign below on any child’s behalf).
I agree to be bound by and obey the terms and conditions and all other rules, regulations and conditions of climbcostablanca and its officials, including those rules, regulations or conditions contained in this Disclaimer and any other applicable safety rules including those put in place on the day.
I acknowledge that I owe a duty of care to myself and others whilst engaging in any activity provided by climbcostablanca to ensure that I do not take any action or steps to do or fail to do anything as to endanger my safety and/or the safety of others.
I confirm that I will not attempt to repair, modify or tamper with any equipment provided to me for any purpose whilst engaging in any activity and will comply with all instructions in relation to the safe and proper use of such equipment.
I will not, whilst engaging in any activity provided by climbcostablanca, use any equipment other than those provided to me by the aforesaid without the consent of a representative of climbcostablanca.
I acknowledge that adventurous activities may be physically and mentally demanding, and that there is a risk of injury or death, and confirm that I am in good health and know of no reason, physically or mentally why I should be unable to engage in such activity.
I agree to pay Kim Jackson a sum equivalent to the new value of the item plus an administration charge of £50 if I fail to return any equipment provided to me for the purpose of engaging in any activity.
I acknowledge and recognise that whilst engaging in any adventurous activity there will be an element of danger and I take part at my own risk. I confirm that Kim Jackson is entitled at any time for any issue relating to safety reasons, to deny me access and/or engagement in any activity. I will not hold Kim Jackson responsible for any illness, loss, injury or death sustained before, during or after participation in an activity provided by climbcostablanca.
I confirm that I understand the necessity to take out suitable insurance for the activity.
I hereby acknowledge the above disclaimer
We love to take group photos of smiley faces out on the hill for our website and social media... please tick this box if you DON'T want us to include any of you.
Mobile: 07843 017521
Landline: 01179 420974