This Form Is Taken on Each Trip and It Is Essential That the Information Supplied Is Correct

MEDICAL QUESTIONNAIRE

Please complete all sections electronically, print, sign and post to 11 St Lawrence Road, Canterbury, Kent, CT1 3EY

This form is taken on each trip and it is essential that the information supplied is correct

PERSONAL DETAILS

Participants name Date of birth

Next of kin name Relationship to you Contact number (Please provide two Next of kin address numbers i.e. home / work / mobile) Second contact Contact number person

MEDICAL INFORMATION (Please use drop down boxes)

Are you allergic to any of the following? Do you suffer from any of the following?

Penicillin No Asthma No

Nuts No Eczema No

Bites and stings No Persistent headaches No

Food allergies No Hay fever No

Other No Other No If you have said yes to any of the above please give further details:

Please give details of any medication (prescribed or otherwise) you take regularly:

Details of your medical history (significant points only please):

Dietary requirement – please complete if you are vegetarian, vegan or unable (for medical reasons) to eat certain foods:

Name, address & telephone Blood group number of your GP (if you know it)

www.canterburygold.org.uk © Copyright Canterbury Gold 2007-2011 Page 1 of 2 IMMUNISATIONS

By the time you leave for your Qualifying Expedition will you be immunised against any of the following? The list below does not indicate that you require these immunisations – you must discuss with your doctor/practice nurse. (Please use drop down boxes)

Diphtheria No Meningitis No

Polio No Rabies No

Tetanus No TB (BCG) No

Hepatitis A No Typhoid No

Hepatitis B No Yellow fever No If you are travelling to Africa you may be advised to take Other Immunisations anti-malaria precautions. If so which malaria tablets are you going to take?

SIGNATURES

Signature (Participant) Counter Signature (Parent / This MUST be signed even if Date Guardian if under 18years) under 18years I confirm that the information given in this Medical Questionnaire is correct to date and I will inform Canterbury Gold of any changes should they arise before participation in any activities with Canterbury Gold.

Should the necessity arise, I agree to the person in charge of the party giving consent on my behalf for an anaesthetic to be administered or for any other urgent medical treatment to be given.