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Upper North Regional Tramp Application Form
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Robyn lost most of her vision suddenly. But thanks to kind Kiwis like you she feels she’s had wonderful support
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About
Upper North Island Regional Tramp
Step 1 of 2
50%
Section 1: Participant details
Name
*
Required
First
Last
Address
*
Required
Telephone
Mobile
*
Required
Email
*
Required
Age/Date of Birth
Emergency Contact Details (during the time of the event)
Emergency Contact Name
*
Required
Emergency Contact relationship to you
*
Required
Emergency Contact address
*
Required
Emergency Contact email address
*
Required
Emergency Contact daytime phone number
*
Required
Emergency Contact evening phone number
*
Required
Emergency Contact mobile phone number
*
Required
Eye Condition
Are you partially sighted?
Yes
No
Are you totally blind?
Yes
No
Corrected visual acuity (if known)
Do you wear glasses?
Yes
No
Contact lenses?
Yes
No
Do you use a cane?
Yes
No
Do you use a guide dog?
Yes
No
In what format do you prefer to receive information?
(e.g. braille, text, CD, large print etc)
How well are you able to use the vision you have in everyday situations?
(e.g. getting around, steps, poor light conditions)
What are your current recreation interests?
What is your walking/tramping and outdoor experience? Please detail these:
Have you previously attended an event similar to this? If yes, what are they?
How would you rate your current level of fitness to attend this event as outlined on the flier description? Rate on a scale of 1 – 10 where 10 is very confident in your fitness for this event.
How would you rate your level of confidence in walking in unfamiliar terrain? Rate on a scale of 1 – 10 where 10 is very confident with no support required?
What is your preferred mode of support for walking? Example: sight guiding, following, verbal
What do you hope to gain from participating in this event?
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
*
Required
Phone
*
Required
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
*
Required
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.
