Upper North Regional Tramp Application Form

Section 2: Health profile and medical consent

(This section is designed to assist with the care of all participants on Blind Foundation programmes)

Family Doctor Name *

Phone *

Medic Alert Number

(if applicable):

Medical/Health Conditions

Please note that if you are selected a medical certificate will be required from your GP before participation in this event. Please indicate yes or no if you suffer from any of the following, and the treatment / first aid that may be required:

Migraine

Yes
No

Asthma

Yes
No

Diabetes

Yes
No

Travel sickness

Yes
No

Seizures of any type

Yes
No

Heart condition

Yes
No

Dizzy spells

Yes
No

Colour blindness

Yes
No

Hearing impairment

Yes
No

Other: please give details of other medical conditions/disabilities

Do you have any allergies?

If yes, please give details below along with treatment.

Are you currently taking medication?

If yes, please state name(s) of health conditions and medications.

Do you have any special dietary requirements?

If yes, please specify.

Do you need any support with personal care?

If yes, please specify.

Please provide any other information that we should be aware of regarding your health and safety:

Declaration *

Yes
No

I, the undersigned, have disclosed all necessary information to ensure my safety and well-being during this event. I understand that places are limited. Also that due to the nature of some activities and / or external provider requirements, additional specific selection criteria may be used. This may mean I may not be selected for participation on this occasion. I will inform the Blind Foundation event coordinator as soon as possible of any changes in my medical and /or other circumstances that may arise between now and the commencement of the programme I understand that any injuries or illness will in the first instance be attended by a Blind Foundation staff member trained in first aid. I agree to receiving any emergency medical, dental, or surgical treatment as may be considered necessary by the medical authorities and that this will be secured at my expense. I consent to be involved in any publicity, including photographs. The staff and volunteers will exercise all due care, but will be clear of all liability in the event of any injury, damage or loss I may sustain to person or property. I have read the event information sheet and I understand that there may be risks associated with involvement in Blind Foundation events and that these risks cannot be completely eliminated. I understand that the Blind Foundation will identify any foreseeable risks or hazards and implement correct management procedures to eliminate, isolate or minimize those hazards.

Name

This field is for validation purposes and should be left unchanged.

Upper North Regional Tramp Application Form

Upper North Island Regional Tramp

Step 1 of 2

Section 1: Participant details

Emergency Contact Details (during the time of the event)

Eye Condition

Section 2: Health profile and medical consent

Medical/Health Conditions