Medical Form – Adult and Child

Event(Required)

I, [insert guardian's full name]...(Required)

on behalf of myself, and as legal guardian of the children listed below, acknowledge and assume all risks associated with participating in any events being conducted by the Bibbulmun Track Foundation (BTF), and will hold the BTF, its Board, Executive Director, employees, servants and agents free from any and all liability, caused of action, debt, claims and demands of every kind and nature whatsoever which may arise out of or in connection with the use of facilities, equipment and/ or participation in the event.

Adult's Email(Required)

Enter Email Confirm Email

Name of Child 1(Required)

Name of Child 2

Diet Restrictions

We have the following diet restrictions (inc allergies).
Write "Nil" if there are none.

Adult's Diet Restrictions(Required)

Child 1's Diet Restrictions(Required)

Child 2's Diet Restrictions(Required)

Age at time of Event

Adult's Age(Required)

Child 1's Age(Required)

Please enter a number from 7 to 18.

Child 2's Age(Required)

Please enter a number from 7 to 18.

Prescribed Medication

During the event I am likely to be taking the following prescribed medication(s). Write "Nil" if there are none.

Adult 1 [medication](Required)

for the following ailments [Adult 1]

Child 1 [medication](Required)

for the following ailments [Child 1]

Child 2 [medication](Required)

for the following ailments [Child 2]

Medical Conditions

Do you have any medical conditions: (please specify any allergies, asthma, diabetes, epilepsy, heart conditions, etc) other than already declared above? If yes, please give details (nature, triggers, treatment protocol)

Adult 1

Yes

Child 1

Yes

Child 2

Yes

Adult 1 Conditions(Required)

Child 1 Conditions(Required)

Child 2 Conditions(Required)

Significant Illnesses

Have you been in hospital or suffered any significant illness or incapacity in the last two years? If yes, please give details (date, condition etc)

Adult 1

Yes

Child 1

Yes

Child 2

Yes

Adult 1 [significant illnesses](Required)

Child 1 [significant illnesses](Required)

Child 2 [significant illnesses](Required)

Emergency Contact Details

In an emergency, please contact

Contact Name(Required)

Relationship(Required)

Contact Number(Required)

Alternative Number

Address(Required)

Event Consent

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