Health and Safety Form

Please ensure that all sections marked ** are filled out correctly

Contact Information
First Name**	Surname**
Address**	City**
country**	Postcode**
County**	Email Address**
Home Phone**(inc country code)	Work Phone**(inc country code)

*In the event of an accident please notify:*
First Name**	Surname**
Address**	City**
country**	Postcode**
Home Phone** (inc country code)	Work Phone** (inc country code)
County**	Relationship**

*If the above person is not available please notify:*
First Name	Surname
Address	City
country	Postcode
Home Phone (inc country code)	Work Phone (inc country code)
County	Relationship

Medical Insurance Details All Participants MUST* have medical insurance that covers this activity.*
Insurance Provider	Policy Number
24hr Contact Number

Vitals
Date Of Birth	Height	Weight
Gender	Resting Pulse	Blood Pressure
Blood Group	Date Of Last Tetanus Protection The danger of Tetanus can be extreme. It is strongly advised that you are innoculated against this fatal disease and you can obtain a booster every 10 years.
Do you have any problems with your eyes or vision? Please Describe
Do you wear prescription glasses or contacts? (We recommend bringing spare glasses or contacts if worn)

Allergies
Are you allergic to stings?
If so how severe are your reactions
Do you carry an Anaphylaxis kit?
Please list all medications to which you have had a reaction (including aspirin). Please also note the strength of reaction.
Please indicate all allergies to food, insects, etc. and please note the severity of the reaction.

Illnesses and Medications Please Indicate any:
Recent Illnesses (Past 12 months)
Accidents, operations, hospitalisations
Recent exposure to infectious disease
Please describe any medications you are taking, why you are taking them and how much and how often (including birth control pills, diamox, insulin etc.)

Physician Details
Physician Name	Contact Number
Address A recent physical examination is recommended and may be a requirement by the trip leader.
Date of most recent physical examination

I certify that I have read and I understand this medical form, and any associated notes and explanations. The information I have given is correct. In the event of my illness or if I am involved in an accident that requires medical assistance, I hereby give permission for the leader and/or any other first-aid trained staff to administer first aid and initiate medical treatment and notify those individuals I have indicated on this form in case of hospitalisation

Please ensure that all sections marked ** are filled out correctly

Health and Safety Form

Contact Information

Medical Insurance Details

Vitals

Allergies

Illnesses and Medications

Physician Details