WE NEED THE MEDICAL DETAILS OF EVERY PERSON ON THE PROPERTY IN THE EVENT OF A MEDICAL EMERGENCY; PLEASE FILL IN CORRECTLY AND COMPLETELY

This includes everyone, competitors, spectators, children, marshals, kitchen staff, etc

 

Surname: Name:
Address: Email:
DOB: Home Tel: Mobile Tel:
Do you suffer from Asthma? Yes No
Do you suffer from Epilepsy or other fits? Yes No
Do you have a heart condition? Yes No
Do you suffer from Blackouts or Dizzy Spells? Yes No
Do you have Diabetes? Yes No
Are you allergic toPenecilin? Yes No
Current Medication we need to know of?
Do you have any food allergies? Yes No If so, please specify
Any other Allergies? Yes No
Doctor's name, address and contact number (if you haven't a doctor, please state "have no doctor")
Next of Kin in case of emergency, inc name, telephone and address:
Anything else we need to know of?
In the event of an emergency do you give consent for us to call an ambulance at our discretion? Yes No