JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Participant Medical Information
Every person (adult and child) attending Kaitoke Outdoor Education Centre programs must provide the below information
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Participant Personal Details
First Name
*
Your answer
Last Name
*
Your answer
Address
*
Your answer
Participant Caregiver Details
Full Name
*
Your answer
Contact Phone Number
*
Your answer
Participant Dietary Information
All questions below are relating to the participant attending camp
Do you have any dietary requirements/ food allergies?
*
Yes
No
Comments
If yes, please state below e.g gluten free
Your answer
Participant Medical Information
All questions below are relating to the participant attending camp
Please tick if any of the below statements relate to you
I have or have had an illnesses such as diabetes, epilepsy, asthma ect
I require regular medication
In the last 6 months I have had treatment for a serious injury
I am allergic to something (eg medication, insects)
I have something else I want people to know about me (eg. I get nervous easily, fear of heights)
Notes
*
Please provide further information below if any of the above boxes were ticked. Otherwise just type 'no'
Your answer
Do you give permission for Y Staff to use photos including the above person for marketing purposes?
*
Yes
No
Next
Page 1 of 2
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
