Pre-physical Activity Checklist

This Form must be completed before any physical activity takes place; it should be signed off by a member of the committee and submitted on the morning of your activity.

Club/Society *
Date of activity Date of activity * / MM / DD YYYY
Venue *
Are there any Medical Conditions affecting your members that we should be aware of before the activity begins? *

Are there any Medical Conditions affecting your members that we should be aware of before the activity begins? Yes No
Please give details
Have any of your team sustained an injury within the last 5 weeks? *

Have any of your team sustained an injury within the last 5 weeks? Yes No
Please give players name Please give players name First Last
Please give details - what type of injury and how long ago?
To the best of your knowledge have all members paid their membership? *

To the best of your knowledge have all members paid their membership? Yes No
Have you completed a risk assessment covering generic venue use and returned it to the Engagement Team? *

Have you completed a risk assessment covering generic venue use and returned it to the Engagement Team? Yes No
Please detail any additional risks that may be relevant for today’s activity
Committee Member - Please draw your signature into the box below. *

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Committee Member Name Committee Member Name * First Last
Email *