Medical Information for activities
We would like you to read the following carefully:

Please complete this medical information form and submit at least 7 days before your booking.  This form must be completed by ALL participants and should be completed and submitted by each participant and on behalf of children aged under 18 by a parent/carer.  Failure to complete this form beforehand will result in non participation.  Paper copies of the form are available upon request.

The information provided on this form is required for the activity staff at Anglesey Adventures (based at Anglesey Outdoors) in order to give appropriate medical assistance if required.

The information will be treated confidentially.  It is essential that we know about any potential health problems.  If on arrival, it is found that information has not been given correctly, we reserve the right to refuse admittance to the course/activity.  If you suffer from asthma or an allergy, please ensure you bring your medication (i.e. inhaler/epipen) with you, you will not be able to proceed with the activity without it.

Illness or medical conditions need not necessarily prevent you from taking part, but we must be aware of any potential problems.

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Name of the group organiser *
Please enter the name of the person who made the initial booking, this could be you if you are the organiser.
Name of participant *
Date of activity *
MM
/
DD
/
YYYY
Age of participant *
Course/Activity Description *
Do you wear contact lenses or spectacles?
If you will need to wear spectacles for your activity, please ensure you bring something to secure them such as sport spectacle straps.
Clear selection
Please answer yes or no to each question then give full details below if you have answered no any of the questions from 2 onwards. *
Yes
No
Are you confident in the water?
Heart trouble or raised blood pressure?
Asthma, bronchitis or tuberculosis?
Diabetes?
Epilepsy, fainting, migraines, severe head injuries?
Nervous illness?
Hay fever, allergies, e.g. medicine, insect bites?
History of fractures or tendon/ligament damage?
Suffering from, or carrying, any infection diseases (including Coronavirus)?
Treated by a Doctor/hospital in the last two years?
Do you have any disability?
Do you have a health problem or condition which is controlled by medication?
Please give details of any medical conditions listed above or not covered
If you contract any illness or suffer any injury subsequent to filling in this form, it is essential that you inform the activity staff at Anglesey Adventures before the course or activity starts.  If you are in any doubt about your physical ability, please consult your doctor.  If you are under 18 years of age, this form must be completed by a parent or carer.
Medical Declaration *
Required
Parents/Carers
Declaration *
Check box to confirm
I can confirm that I am the participant named above OR completing the form as a parent/legal carer on behalf of the child(ren) named above.
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