Saturday 11th August 2012
Please complete all sections of this form and return it to: Fundraising Department, Liverpool
Cathedral, St James House, 20 St James Road, Liverpool, L1 7BY
Before completing this form please read carefully the Conditions of Entry which are listed
below. Please write clearly and complete all the sections listed.
I will be raising money for LIVERPOOL CATHEDRAL FOUNDATION
HOW DID YOU HEAR ABOUT THE ABSEIL EVENT?
Please let us know how you found out about it_____________________________________
PERSONAL DETAILS (please use capital letters)
Title _______________ Forenames_______________________________________________
Home phone ________________________ Mobile__________________________________
Email__________________________________ Date of Birth__________________________
(You must be at least 18 years of age to take part)
The abseil event is scheduled for 11th August however the abseil cannot take place during
extreme weather conditions and will be rescheduled to 17th August or 18th August 2012 if
necessary. Please tick the box to confirm that you are available for all the dates, as it will not
be possible to refund money if you can not make the alternative dates.
□ I confirm that I am available on the 11th August, 17th August and 18th August 2012.
There will be two working abseil ropes so friends or partners can abseil at the same time, if
you would like to abseil with someone please list their name above. (Please note we cannot
guarantee your request, but will try our best.)
□ Solo abseil □ Partner Abseil: Name of Partner: _________________________________
Please indicate below if you have any pre-existing medical conditions or are on any
medication. We may ask you to provide a doctors note confirming you are fit enough to take
part if necessary. Please note in addition to the 150ft free fall abseil participants will have to
climb 224 steps up the tower to access the abseil platform.
Pre existing medical conditions (include details about asthma, diabetes, epilepsy etc.)
Details of any hospital treatment in the last 12 months_______________________________
Are you allergic to anything? (E.g. penicillin, plasters etc.)_____________________________
NEXT OF KIN DETAILS
Name (in full) ________________________________ Relationship_____________________
Home Phone _________________________Mobile__________________________________
CONDITIONS OF ENTRY
In order to participate in the abseil event you must read and agree to the following terms
and conditions and sign the declaration at the bottom of the form. I agree that:
I am over 18 years of age.
I have paid a registration fee of £35 (non-refundable) and I agree to raise at least £120
sponsorship for Liverpool Cathedral Foundation to qualify for my place. All funds raised
in connection to this event should be paid directly to Liverpool Cathedral Foundation.
If I have to withdraw from the event, all sponsor forms and monies should be forwarded
to the charity or returned to the sponsors. If I am unable to meet the sponsorship money
requirements, I will forfeit my place or I may choose to make up the balance myself.
I am in a good state of medical and fitness health and have declared any medical
conditions on this form and I take full responsibility for my own fitness to take part.
I am able to participate on the 11th August 2012 and the backup dates of 17th August
2012 and 18th August 2012.
I am aware that abseiling is an activity with a danger of personal injury or death; and
accept these risks and responsibility for my own actions and involvement.
In the event of illness or an accident at the event I hereby give my permission for
Liverpool Cathedral or Awesome Walls Climbing Centre first aiders to initiate medical
treatment and notify my next of kin in case of hospitalisation.
I agree to abide by the rules and instructions given by the abseiling instructors to me on
the day of the event.
I understand that any participant who has been drinking alcohol, taken drugs or behaves
irresponsibly; in such a way to risk his/her safety or that of other participants or the
instructors will not be allowed to participate in the abseil event and may be asked to
leave the Cathedral site.
I understand that Liverpool Cathedral is a Grade 1 listed building and a place of worship
and agree to respect the building and will not cause any damage to the fabric of the
I confirm that the above information is correct and if any information changes I will
inform Liverpool Cathedral.
I apply to take part in the Liverpool Cathedral Charity Abseil, and abide
by the Conditions of Entry listed above
Signature Name (capital letters) Date
___________________ __________________________ ______________