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Participant Consent Form
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* Indicates required question
Email
*
Your email
Which date fo you wish to attend the event?
*
Sunday 14th August 2022 - 03-00 hrs
Sunday 11th September 2022 - 04-00 hrs
Participant Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Email Address
*
Your answer
Home Address
*
Your answer
Phone number
*
Your answer
Doctor's Name/Phone Number
*
Your answer
Emergency Contact 1 - Name / Phone number / Relationship to Participant
*
Your answer
Emergency Contact 2 - Name / Phone number / Relationship to Participant
Your answer
Please detail any medical / dietary conditions of which staff should be aware. This includes allergies:
Your answer
Please list any medications which the Participant will have in their possession. Please include inhalers or epi-pens in addition to other treatments (including non-prescription medications) and where possible dosages and timings:
*
Your answer
Has the Participant had any other recent illness or injuries that may affect their ability to participate fully in the training and/or event?
Yes
No
Clear selection
If Yes please give dates and details
Your answer
Are you allergic to any drugs ?
*
Yes
No
If Yes please list these drugs
Your answer
Is there any other health issues you consider relevant to your participation in this activity
*
Your answer
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