Parental Consent Form Under 16s The Base Under 16's This for is for riders under the age of 16 years old. A Parent or Guardian must complete before the rider can participate. Parent or Guardian DetailsParents / Guardian's Name* First Last Address* Street Address Address Line 2 Town / City County Post Code / Zip Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Contact Phone Number*Email Address* Rider DetailsFull Rider Name* First Last What is your prefered activity?*BMXSkateboardScooterMountain BikeInline SkatesSpectatorPhoto StudioDate Of Birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Please Detail Any Medical Conditions Please detail any current medications and allergiesEmergency Contact DetailsEmergency Contact Name* First Last Emergency Contact Phone Number*By signing this Consent Form you consent that you will be participating in an Extreme Sport that can be dangerous and accept that you use the facilities at THE BASE entirely at your own risk and that you will not hold THE BASE Skatepark CIC, Directors, or employees liable in any way whatsoever for any injuries which result from using or spectating at these facilities or for any accidents, loss or damage or death whilst on these premises save in the case of negligence. If you sign this form you will be giving permission for THE BASE to obtain medical help in the event of an injury or illness. I confirm that I have read and understood The Base Skatepark rules, terms and conditions and have been strongly advised that I should wear full protective equipment, therefore taking full responsibility for my actions. I am also fully aware of the risks involved with extreme sports and use the entirely at my own riskk.Please read and confirm all of the following* I confirm I have read and understood The Base Skatepark rules, terms and conditions I confirm I will not hold The Base Skatepark CIC, Directors or Employees liable for any acts, omissions or adverse results of any medical treatments administered I confirm I will keep the details given above correct and up to date with The Base Skatepark and doing so is my responsibility I agree for this person to participate in an Extreme Sport at The Base Skatepark I agree for The Base Skatepark to contact me with news, updates and occasional promotions
