Medical Consent Form

Medical Consent Form

This form is to be completed prior to your attending any MountainSphere trip. Information you provide on this form is kept strictly confidential. The purpose of this form is to ensure I have necessary information for your safety on the hike.
Your Name*

First NameLast Name
Mobile Phone Number*
Please enter a valid phone number.
Email*
Your email address.
Which Trip are you Attending?
Select from the list of MountainSphere trips.
Trip Date

DayMonthYear
The scheduled start date of your trip.

Emergency Contact Details

Is there anyone who you would wish to have contacted in the event of an emergency?
Emergency Contact Name

First NameLast Name
Relationship
The emergency contact person's relationship to you. Optional.
Emergency Contact Phone
This is your emergency contact person's phone number
Emergency Contact Email
Your emergency contact person's email address

Asthma Action Plan

Please advise what your asthma action plan is in the event that you experience asthma on the trip.
What is your preventer medication?
Eg: Seratide inhaler - to prevent onset of asthma
What is your reliever medication?
Eg: Ventolin inhaler - for immediate relief of asthma symptoms
Will you be carrying your preventer and reliever medication on the trip?

Yes, both reliever and preventerReliever onlyPreventer onlyI will not be carrying any asthma medication
Anything else to add regarding your asthma?
In this section please provide details of your Asthma Action Plan. For example, how many puffs of which medication and how often, in the event of mild/moderate/severe asthma. Your Asthma Action Plan would have been prepared in consultation with your asthma doctor to manage your asthma condition.
Asthma suffers must bring all asthma medication, preventers, relievers, spacers etc with them on the trip. The group first aid kit includes ventolin but no prescription asthma medication.

Your Privacy

Please accept the privacy statement below
MountainSphere Adventures and Education will collect and store the information you voluntarily provide when submitting this form. In submitting this form you consent to this.

The information will be kept strictly confidential and used only for the purpose for which it is intended. It may be used to provide you or arrange to provide you medical treatment that may be required. The information may be shared with medical professionals, paramedics or other health professionals as required. You consent to these disclosures.

You may request access to or deletion of your medical information at any time.
Your Consent to Medical Treatment

Please accept the terms below
In the case of an emergency, I authorise MountainSphere Adventures and Education staff, where it is impracticable to communicate with me, to arrange for me to receive such medical or surgical treatment as may be deemed necessary. I also undertake to pay or reimburse costs which may be incurred for medical attention, evacuation, ambulance transport and medication while attending the trip.
Your signature*

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Emergency Contact Details