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Medical Form for Trips

Please ensure you complete this form and submit it along with any relevant Medical Clearance from your Doctor, to secure your place on any of our Wild Weekenders or multi-day trips.

Medical Clearance is required if:

·          you answer YES to any of the  questions under the Section titled: Medical Considerations;

·          you are over 55yrs; or

·          if you are an On-line Member taking part in a trip

Please ask your Doctor to complete the attached Medical Clearance Form

Name*
Mobile Number*
Email *
(email address)
Date of Birth*
(DD/MM/YYYY)
Wild Walk/Weekender/ Trip Name and Date*
Emergency Contact Name and Number*
Have you ever had any injury, illness, back or joint condition that may be aggravated by strenuous exercise?*
YES NO
Are you now or have you recently been pregnant?*
YES NO
Is there any other medical condition that might be reason to modify your plan to participant in this trip/event? If yes, please outline*
YES NO
Have you had any allergies or reactions to any medical drugs or food?*
YES NO
If you answered YES to any of the above questions, please provide further details here
Please list any medication you take on a regular basis & any known side effects
MEDICAL CONSIDERATIONS: Have you had any of the following medical conditions? Tick relevant box to indicate YES
High blood pressure or any heart condition? Asthma, Diabetes, or Epilepsy? Depression, Anxiety or Mental disorder? Do you have any family members who have had heart problems prior to age 60? Is there any other medical condition that we should be aware of?
If you ticked YES to any of the conditions listed under MEDICAL CONSIDERATIONS, please provide further details here
I understand that all exercise programs have certain risks, and I accept that I am responsible for my own safety in undertaking an exercise program with WWoT.*
YES
I will take it upon myself to discuss any changes in my current health with WWoT personnel.*
YES
Declaration: I declare that the answers to the questions in this form are true and complete. I agree to this information being made available to the Chief Medical Officer (CMO) accompanying any event organised by WWoT*
In the event of an accident or illness in the course of any activity with WWoT, I hereby give my permission for the CMO to initiate medical treatment and to inform my Emergency Contact and/or my next of kin in case of hospitalisation.*
I agree to provide WWoT with the relevant Medical Clearance Forms from my Doctor, where required, and understand that if I fail to provide these, I will not be eligible to partake in this Trip/Wild Walk/Weekender*
AGREE
Applicants Initials*
Todays' Date*
(DD/MM/YYYY)
Verify*
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