Undercover Rock - Course Booking Form

Use one booking form per person per course and please write in BLOCK CAPITALS. Acceptance of booking is subject to receipt of a signed booking form with payment.

PERSONAL DETAILS

 Title:

 Forename:

 Surname:

 Age:

 Date of Birth:

 Address:

 

 

 Postcode:
 Telephone Day:
 Mobile:

 E-Mail Address:

EMERGENCY CONTACT

 Name Of Contact:

 Contact Number:
 Relationship To Contact:
COURSE DETAILS

 First Choice:

Course Title:

Course Dates:

 Second Choice:

Course Title:

Course Dates:
MEDICAL CONDITIONS

 Please give details of any medical conditions, allergies or significant disabilities:

 

 

 
PREVIOUS EXPERIENCE

 Please summarise previous experience of your chosen activity :

 

 

 

 

 

 
Please indicate if you need us to provide:
Harness Y / N
Rock Shoes (state size) Y / N ..............
Karabiner and belay device Y / N

COURSE FEES
The balance of your course fee is due 2 weeks before the start of your course. Please read the terms and conditions regarding cancellation by the client.

The full fee for my course is £

I am paying a deposit / the full course fee of £
I enclose a cheque payable to 'Undercover Rock Ltd' / have entered my Credit (there is a £2 charge for all credit cards) / Debit card details below. Please note we are unable to accept Diners or Amex cards.
 Card No:
       
       
       
       
     
         
 Valid From:
       
 Expires:
       
 
   
 Issue No (Maestro Only):
   
Cardholder's Signature

Cardholder's Address (if different from above)

 

 

Postcode:

I confirm I have read and understood the booking terms and conditions and that I agree to accept and abide by them. Under 18's require a separate parental consent form, available on request.

 

Signed__________________________________

Date________________

  

Please return this form together with your payment to: Undercover Rock Ltd, St.Werburgh's Church, Mina Road, Bristol, BS2 9YT or fax to: 0117 9542425 or email to enquiries@undercover-rock.com