Pure Latitude
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Medical Form
Name of Event
Date
*
DD slash MM slash YYYY
Name
*
Address
*
Date of Birth
*
DD slash MM slash YYYY
Contact Number
*
Email:
Health
Are you, to the best of your knowledge, fit to complete the activity
*
Are you, to the best of your knowledge, fit to complete the activity
Yes
No
Do you suffer from epilepsy, disability, giddy spells, diabetes, deafness, heart disease, angina, asthma or similar ailment?
*
Do you suffer from epilepsy, seizures, diabetes, abnormal blood pressure, heart disease, angina, asthma or similar ailment?
Yes
No
Do you suffer from deafness, visual impairment or any other disability that may affect your learning?
*
Do you suffer from deafness, visual impairment or any other disability that may affect your learning?
Yes
No
Please specify if yes to the above:
Are you on any form of medication (if none write none)?
Dietary Requirements
Next of Kin
Please make sure it's someone that's not on the activity with you.
Name
*
Address
*
Number
*
Declaration
*
I declare that the responses I have given above are correct to the best of my knowledge and I know of no reason related to my health and well-being that will prevent me from undertaking this activity. I will inform the skipper/instructor immediately if I have any difficulties during the activity.
Phone
This field is for validation purposes and should be left unchanged.
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