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Medical Information
MEDICAL INFORMATION FORM, NEXT OF KIN AND EMERGENCY DETAILS
Step
1
of
3
- Details & Medical Info
33%
Paddler's details
Name
First
Last
Email
*
Medical Insurer
Member’s Number (if available)
Emergency telephone No. of Insurer
With regards to going paddling, do you have any current medical illnesses, disabilities or infirmities that require specific care and that we should be aware of?
Yes
No
Please provide a brief description in case of emergency.
Have you been hospitalized or had recent surgery that we should know about with regards going paddling?
Yes
No
Please provide a brief description in case of emergency.
Do you have any chronic medical conditions that we should know about with regards going paddling (e.g. heart, respiratory, diabetes etc.)
*
Yes
No
Please acknowledge you will have necessary care and medication available
*
I will have the necessary care related to my condition readily available
Do you have any dietary restrictions, food allergies, drug allergies or other allergies (eg. bluebottles, jelly fish)?
*
Yes
No
What are they?
Please acknowledge you will have necessary care available
*
I will have the necessary allergy (eg epi-pen) care readily available
Do you need to wear glasses for paddling?
*
Yes
No
Please acknowledge that you will use an adequate headstrap.
*
I will bring an adequate headstrap for my glasses.
Covid Screening
I hereby certify that I have not been recently treated for, nor am I aware of any physical or other conditions or disability that would create an unreasonable risk to myself or pose a hazard to other participants in the activity.
*
Yes
No
Covid Questions: Have you in the last 14 days...
Had a cough?
Had a sore throat?
Shortness of breath or difficulty breathing?
Lost your sense of taste or smell?
Had direct contact with someone who has contracted the Corona virus disease?
Next of kin
Name
First
Last
Relationship
Personal Phone
Work Phone
Email
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Signature
*
I hereby certify that I have not been recently treated for, nor am I aware of, any physical of other conditions or disability that would create an unreasonable risk to myself or pose a hazard to any other members of the activity.
I Agree and Accept