Booking Form Date Course Name* First Last Please gives names (and ages if under 18) of other participants in this booking.British Canoe Membership Number (if applicable) Date of Birth DD slash MM slash YYYY Only required if attending a British Canoeing Course. British Canoeing Courses* I am aware of the additional costs associated to the course I am booking on and have read the information below. By ticking this box I am confirming I have read this information and have enquired with Rooted in Nature before making payment for this course if I am unclear. Not applicable (e.g. booking on First Aid course- certificate fees are included). PLEASE READ CAREFULLY. These are additional fees you need to pay to British Canoeing and are NOT part of the course fees you pay to Rooted in Nature CIC. If you are attending the Paddlesport Safety and Rescue Course and you are NOT a British Canoeing Member there will be an additional fee of £5.20 cash to bring on the day. If you are attending the Paddlesport Instructor or SUP Instructor it is a pre-requisite to be a British Canoeing Member (£47 adult) AND register for the course (£46.80). If you are attending the Coach Core - you need to be a British Canoeing Member (£47 adult). If you are attending a Sheltered Water Coach training it is a pre-requisite to have completed the Coach Core therefore you should have membership unless it has lapsed. There is also an additional registration fee of £46.80 to British Canoeing. If you are attending the Paddlesport Leader Assessment you need to be a British Canoeing Member (£47 adult) and registration/ check in fee of £40.56. Mobile Phone*A number that you can be contacted on on the day of your booking encase anything changes such as adverse weather.Address* Street Address Address Line 2 City County Post code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email* Enter Email Confirm Email Do you have any medical conditions?* Yes No Please share in the box below.Do you have any allergies?* Yes No Please share in the box below. Including food allergies as we provide brew kit and snacks and will accommodate where possible. Please give any further information you feel we should be aware of before the course including any relevant medical information including allergies and dietary requirements that we can try and accommodate for if we are providing food/ brews.*Please share if there is anything from a learning / teaching perspective that we can support you with.WATER BASED COURSES ONLY: Please give details of your paddling experience, water confidence, preferred craft, courses you have previously attended.Covid-19 - Please tick to say you have read and confirmed the following information.* I confirm I have read and understood the information regarding Covid-19. As you will be aware the requirements are currently pretty non existent but the virus is still around so please be sensitive to each other's wishes in this area. If you would like a copy of the full risk assessment please email me and I will send you one. So please note the following: • Guidelines now state that you are no longer legally required to self isolate if you have Covid-19 but that you should try to stay at home and away from others to avoid passing on the virus. The guidelines state that if you have tested positive for Covid then you should try to avoid contact with others for 5 days. Please contact us if you have any concerns. • Please bring your own mask (to wear if you feel unwell) and hand gel (we will also provide). • Masks are optional but if you are feeling unwell we recommend you wear one in the room to protect others. • Please remain vigilant and commit to washing hands regularly/using gel.Photo Consent* Yes No Photos maybe used on social media such as Facebook and Instagram along with advertising through our website and any other Rooted in Nature CIC marketing. Emergency contact number*Please provide an emergency contact number of someone not on the courseTerms & Conditions* I have read the T&Cs. By ticking this box you are confirming you have read the terms and conditions including cancellation fees. Quantity*Please enter number of places you are booking for. Outdoor First Aid Course Price: Total £ 0.00 Payment* Card Invoice PLEASE NOTE there is a technical glitch with website (we are in the process of building a new one!) and if you click pay by invoice after clicking submit it will take you to the card payment page. Just click back. Give it a few minutes and an email will come through to say we have received your booking. Please check before booking again. We are sorry for any inconvenience!Credit Card American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20232024202520262027202820292030203120322033203420352036203720382039204020412042 Expiration Date Security Code Cardholder Name Invoice Details (Name & FULL Address & Email address if diffierent to above)
