Medicine walk sign-up

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Please fill in relevant information to register for the medicine walk.

Email *

Name *

Address *

Phone number *

Date of walk *

Name and contact for next of kin *

Lift sharing - select one. We encourage people to share lifts. Better for everyone, however you are also welcome to go on your own steam. *

If you need or can give a lift, what area on you in ? *

For your own safety, you need to disclose if you are suffering from, and/or conditioned by, any of the following:

Pregnancy

Suicidal ideation

High blood pressure

Mental illness

MAO inhibitors or anti-psychotic medication

Epilepsy and other seizure related conditions

Diabetes including low blood sugar and hypoglycemia

Heart disease or any current/past issues relating to heart problems

No serious medical or psychological conditions

Please elaborate if you selected any of the above except for the last option.

List any physical disabilities, allergies, conditions, past injuries or anything else that could affect your participation:

Any additional comments or questions.

I agree that I am solely responsible for myself. We guide and support everyone in the group and we expect everyone to be accountable for themselves. I release and discharge Ryan Klette and Leeane Klette from, and against any and all, liability arising whatsoever from my participation in this event. *

Booking instructions

Banking details - Ryan Klette FNB 6201 288 0838 Hyde Park. Please use name as a reference. The cost of the walk is R 500 which includes the entrance fee.

50% deposit secures your place.

Thank you, we look forward to walking with you.

A copy of your responses will be emailed to the address you provided.

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