Medical Form – Travel Partner

Your Details

Your Name(Required)

First Name Last Name

Email(Required)

Preferred Phone Number(Required)

Medical & Indemnity

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

acknowledge and assume all risks associated with participating in the Bibbulmun and Beyond Tour, and will hold the Bibbulmun Track Foundation & its Board, Executive Director, employees, servants, agents & members free from all liability, causes of action, debts, claims, & demands of every kind & nature whatsoever which may arise out of, or in connection with using the Foundations facilities or equipment, or participating in this tour.

My family doctor is

Address

Tel

During the tour I am likely to be taking the following prescribed medication:

for the following ailment(s)

Do you have any medical conditions: (please specify any allergies including those to specific food types, diabetes, epilepsy, heart conditions, etc) other than the dietary requirements already declared for you by the person who made your booking?

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

Emergency Contact

Contact Name(Required)

This person cannot be someone participating on the tour.

First Name Last Name

Relationship(Required)

Tel (h)(Required)

Tel (w)

Address(Required)

Name of the Person that made the original booking(Required)

This should be the full name of the person you are travelling with.

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