Charities Data collection - Corporate & Charity Events with Ultimate Challenges

CHALLENGE DETAILS

Challenge name*

Charity name

Date of trip*

PASSPORT INFORMATION

Passport photo

Full passport name

Email address

Nationality*

Passport number

Date of birth*

Date of issue

Date of expiry

Place of issue

MEDICAL DECLARATION

Height*:

Weight*:

Raised blood pressure*: yesno

Heart or circulatory failure*: yesno

Blood clots - in particular, DVT (clot in leg) or PE (clot in lung)*: yesno

Chest or lung disease*: yesno

Asthma*: yesno

Epilepsy*: yesno

Diabetes*: yesno

Digestive or bowel disorders*: yesno

Haematological or blood disorders*: yesno

Cerebral disease e.g. stroke, head injury, tumour*: yesno

Past injuries e.g. fractures or sprains*: yesno

Operations*: yesno

Mental health problems*: yesno

Allergies*: yesno

Heat or cold injury*: yesno

Please list any medication you are currently taking (if none, state ‘none’)*

If you have any other medical conditions not disclosed above, please give further details. For any medical conditions that have been disclosed above please give further details:

Comments:

Dietary

Dietary requirements*

NEXT OF KIN CONTACT INFORMATION

First name*

Last name*

Relationship*

Daytime phone number*

Evening phone number*

Mobile phone number*

Email

ALTITUDE (if applicable)

Are you taking part in a high-altitude trip? yesno

(Please note All participants taking part in a high altitude treks will be sent a separate medical form which needs to be signed by their GP)

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