Medical Declaration and Consent Form

1
Name* This field is required.
First Name
Last Name
2
Name and date of event attending* This field is required.
3
Email* This field is required.
example@example.com
4
Phone Number* This field is required.
Please enter a valid phone number.
5
What is your Instagram handle?* This field is required.
6
Do you have any existing medical conditions that could affect your successful participation in your booked event?* This field is required.If YES please give a full and detailed answer below.
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7
Are you taking any medication?* This field is required.If YES please give information below.
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8
My emergency contacts name is blanks * and they can be contacted on then following telephone number blank *
9
My doctors surgery is blanks * and they can be contacted on the following telephone number blank *
10
I accept that if I am part of an emergency the details I have provided above can be shared with the necessary authorities involved.* This field is required.
YESNO
11
Fitness Participation * This field is required.
12
Personal Activity Insurance * This field is required.
13
Booking and Attending Terms and Conditions * This field is required.
14
Have you completed this form on behalf of a minor?If yes please give your full name and relationship to the child below.
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Should be Empty: