First name
Last name
Age
Activity
Activity Date
Address Line 1
Address Line 2
Town/City
Postcode
Email Address
Telephone Number
In the event of an emergency:
Next of Kin Name
Next of Kin Telephone Number
Further Information: Do you have a medical condition? YesNo
If yes, what is the nature of your medical condition?
Do you have any other conditions or disability? YesNo
Are you receiving any medication for any condition? YesNo
Are you suffering from any injury? YesNo
If you answered yes to any of the above questions please give further information.
It is your responsibility to make known any potential medical conditions that may affect your own personal safety during the activities associated with the course/event.
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