DU135 2023 Athlete, Crew & Volunteer Medical Information
This information will be kept and sealed and only used in the case of an emergency by Event Organisers and Medical Team. Once the event is complete all will be destroyed for privacy reasons.

We ask you are very thorough and detailed in your explanations pertaining to your medical history, the more information our medical team and emergency services have better they can help you.

All runners, crew members & volunteers MUST complete prior to taking the course.

Please contact Dion Milne 0408 207 196 if you have anything to discuss.
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Email *
Full Name *
Phone Number (that you will be contactable on during DU135) *
Status *
If you are part of an athletes crew please provide the name of your athlete below
Date of Birth *
MM
/
DD
/
YYYY
Address *
Current medications *
Medical History *
Allergies *
Emergency contact name / number (ensure this person is contactable on the event dates and not involved in the event or on course) *
Blood Type (if known) *
Required
AMBULANCE COVER IS A CONDITION OF ENTRY / MANDATORY FOR COMPETITORS &  RECOMMENDED FOR ALL CREW MEMBERS. ​

Emergency ambulance services are NOT free. Did you know that the average cost of an emergency transport is more than $1100? Imagine what an air lift is worth.

SOME AUSTRALIAN STATE AMBULANCE SERVICES DO OFFER AFFILIATED MEMBERSHIP FREE IN THEIR SERVICES, CONTACT YOUR PROVIDER TO SEE IF YOU HAVE VICTORIAN COVER

PLEASE NOTE POINT 4 OF THE WAIVER
*
Required
Waiver (entrants, crew, volunteer to initial)
1.I acknowledge that this event involves competing on roads and tracks, all of which may be utilised by other users. I acknowledge that there are dangers involved in this event including (but not limited to): the condition of participant’s equipment; road, track and traffic conditions; inclement weather; hypothermia; fire; heat exhaustion; venomous snakes; and actions of participants and non-participants. I accept the risks associated with this event.
2.I certify that I have not been advised not to compete in this event by a qualified medical person and that I have undertaken sufficient training to do so safely.
3. I accept all risks necessarily flowing from my participation that could result in death or injury, including permanent disability. Accordingly, I release all persons or corporations associated directly or indirectly with the conduct of the event from all claims, demands and proceedings arising out of my participation and I hereby indemnify them against all liability (including liability for their negligence and the negligence of others) for all injury, loss or damage arising out of or connected with my participation in this event. This release shall extend to and include Australian Ultra Runners Association Inc. (AURA) and its respective directors, partners, managers, officers, agents, contractors, employees and volunteers including medical and paramedical personnel appointed for the event, the owners, licensees and occupiers of land upon which the event or any part of it is conducted, any statutory body or local authority having control over any land upon which the event or any part of it is conducted or which is involved directly or indirectly with the event in any manner whatsoever and promoters, sponsors and event organisers. This release and indemnity continues forever and binds my heirs, executors, personal representatives and assigns.
4. I consent to receiving any medical treatment including ambulance transportation that the event organisers consider appropriate during or after the event and take all responsibility (including responsibility for costs) therefore.
5. I consent to AURA and event sponsors using my name, image and likeness before, during or after the event for event promotional broadcasting or reporting purposes in any media. I also consent to having my name placed in the AURA database for the receipt of newsletters and other promotional material relating to the sport of ultrarunning.
6. I understand that safety precautions undertaken by organiser/s (such as course supervision, gear checks and race safety briefings) are a service to me and other competitors but are not a guarantee of safety.
7. I am fully responsible for the security of my personal possessions at the event.
8. I agree to abide by the race rules and directions issued by the event organiser/s.
9. The event organisers may change the race format, course or other race conditions at their discretion. Should such change occur then this agreement applies to the changed conditions.
10. It is acknowledged that the event is staged on behalf of the Australian Ultra Runners Association Inc (AURA) and that it is being conducted by the Race Director (RD) in his/her capacity as a member of AURA.
11.There will be no refund of entry fees after March 1 2023) for any reason including rescheduling or cancellation due to any natural disaster or Department of Environment and Conservation (DEC) trail closure.                                                                                                              Initials: I Agree
*
A copy of your responses will be emailed to the address you provided.
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