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For young people under 16 yrs, this form must be completed by parent(s) or guardian(s) in the presence
of a Dynamix member of staff or volunteer, or signed by parent(s) or guardian(s) and countersigned by a
responsible adult witness.
Skateboarding, BMX, Inline skating, Scooting, Trials Riding, Circus Skills & Free-running are
hazardous activities; All members are strongly recommended to wear full protective clothing –ie.
kneepads, wrist guards and elbow pads. Helmets MUST be worn for ALL wheeled sports activities
and Stilt -walking. Dynamix Extreme will supervise the park with qualified First Aiders and volunteers but
it cannot accept any responsibility for accidents which may occur as a result of the activities of
Skateboarding, BMX riding, In-line skating, Scooting, Trials Riding, Circus Skills or Free-running.
May any film footage or photographs taken of you/your child be used either for publicity or
displayed at the park?
YES…….. NO……….
Do you/does your child have any medical conditions, eg, epilepsy, asthma, etc
which we should know about in the event of an accident? Please include any
allergies which could affect treatment, or any reason why you should not be
doing physical activity.
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Address……………………………………………………………….
Address…………………………………
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Next of Kin Telephone Numbers (Essential)
Home ……………………………………… Work ……………… …. Contact
Tel……………………
Dynamix Extreme, at Albany Rd, Gateshead, NE8 3AT www.dynamixextreme.com Tel: 07793045420 or
07855110906 | Company Number 06362932