| MEDICAL FORM - Competitor |
| ALL INFORMATION PROVIDED IS CONFIDENTIAL |
| Details |
| Team Code |
Team Name |
Race |
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| First Name |
Last Name |
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| Email Address |
Mobile Number |
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| Home Address |
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| Date of Birth (dd/mm/yyyy) |
Age at Race Start |
Gender |
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| Emergency Contact Person |
Emergency Contact Phone Number |
What is their relationship to you? |
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| Emergency Contact Person’s Address |
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Emergency Contact Person 2 |
Emergency Contact Phone Number |
What is their relationship to you? |
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| Emergency Contact Person’s Address |
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| Questions |
| Do you have any medical conditions currently and /or have had previously? |
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| If yes, please specify what type? |
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| Are you currently taking any medications? |
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| If yes, please specify type, amounts you take, brand name and the most important cause of taking these. |
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| Are you allergic to any medications? |
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| If yes, please list: |
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| Please list any allergies you have and if you are currently being treated for them? |
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| Do you wear a medic alert bracelet or tattoo? |
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| Have you recently experienced or been diagnosed with any of the following? |
| AsthmaHigh blood pressureMigraineEpilepsyLow blood pressureHeadachesNumbness in limbsDizzinessLoss of hearingNausea/vomitingFainting attacksIrregular heartbeatBlurred visionBlackoutsHepatitis
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| Have you had any previous injuries? (ie. Spinal injury, ligament damage or reconstruction) |
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| If yes, please list: |
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| Is there anything else pertaining to your health that we should know about (ie. chance of being pregnant?) |
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| Do you wear contact lenses or glasses? |
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| If yes, will you have spare lenses or glasses? |
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| Name of your current insurance |
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| Name of your doctor |
Phone number of your doctor |
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| Your doctor’s work address |
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| Declaration |
- I declare that the information given in this form is true and complete to the best of my knowledge.
- I certify that I am physically fit, have sufficiently trained for participation in the GODZone Adventure Race, and have not been advised otherwise by a qualified medical person.
- I acknowledge that in accordance with the provisions of the Privacy Act 1993 the following information has been brought to my attention
- This form collects personal information about me.
- The intended recipients of the information are those staff directly involved with safety and medical on course.
- This information is being collected and held by 100% Pure Racing.
- The privacy Act 1993 entitles me to have access and request a correction of the information
- I declare that the information given in this form is true and complete to the best of my knowledge.
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| I declare |
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