Medical Form

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.

Health