ALPINE RIVER ADVENTURES
Multiday Wilderness Expeditions
6 day Snowy River Byadbo Wilderness Expedition
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6 Day itinerary
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Medical Form
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Indicates required field
Trip Date
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Personal Details
Name
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First
Last
Date Of Birth (dd/mm/yy)
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Email
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Phone
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Medicare Number
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Valid to
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Doctors name
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Phone
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Primary Emergency Contact Details
Emergency contact name
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Relationship to you
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Contact number
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Second contact number
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Medical Details
Travel insurance (recommended)
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Yes
No
Notes
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Ambulance subscription (recommended)
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Yes
No
Notes
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Asthma
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Yes
No
Notes
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Allergies
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Yes
No
Notes
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Joint/Muscle/Skeletal issues
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Yes
No
Notes
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Disability
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Yes
No
Notes
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Please list any other medical conditions and medications
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* Please note it is your responsibility to inform us of any medical conditions. You are responsible to carry and administer your own medication. You may ask staff for advice on how to securely carry your medication while on the river.
Dietary
Any special requirements?
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Yes
No
If yes please provide details
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Swimming Ability
I can swim 50 metres
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No
With a struggle
Comfortably
Strongly
Sizing
Height (cm)
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Weight (kg)
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Fitness Level
My level of fitness is
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Low
Average
Good
Excellent
* Please note Alpine River Adventures may require, after reviewing this information that you visit a doctor to gain approval to participate. This will be determined after this form is received by Alpine River Adventures and in consultation with you.
Declaration
I declare that the information which I have provided on this form is complete and correct and that I will notify Alpine River Adventures if any changes occur. I authorise the guide or any employee of Alpine River Adventures who is with me, to give consent where it is impractical to communicate with me, and agree to me receiving such medical or surgical treatment as may be deemed necessary. I give permission for Alpine River Adventures to pass this information on to a third party (e.g. Doctor, Hospital) to facilitate my medical treatment. I give permission for Alpine River Adventures to retain this form for statutory requirements.
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I accept this declaration
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