Medical Form - General - Bibbulmun Track Foundation

Event(Required)

I, [insert full name]...(Required)

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.

Diet Restrictions

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

Diet Restrictions(Required)

Age at time of Event

My Age(Required)

Prescribed Medication

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

Medication(Required)

for the following ailments

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). Write "Nil" if there are none.

Medical 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). Write "Nil" if there are none.

Significant Illness(Required)

Emergency Contact Details

In an emergency, please contact

Contact Name(Required)

This person cannot be someone participating on the event.

Relationship(Required)

Contact Number(Required)

Alternative Number

Address(Required)

Booking Confirmation

Full name of person that made this booking for you:(Required)

Event Consent

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Medical Form – General