Medical Form

ALPINE RIVER ADVENTURES

Medical Form

* Indicates required field

Trip Date *

Personal Details

Name *

First

Last

Date Of Birth (dd/mm/yy) *

Email *

Medicare Number *

Valid to *

Doctors name *

Phone *

Primary Emergency Contact Details

Emergency contact name *

Relationship to you *

Contact number *

Second contact number *

Medical Details

Travel insurance (recommended) *

Yes No

Notes *

Ambulance subscription (recommended) *

Yes No

Notes *

Asthma *

Yes No

Notes *

Allergies *

Yes No

Notes *

Joint/Muscle/Skeletal issues *

Yes No

Notes *

Disability *

Yes No

Notes *

Please list any other medical conditions and medications *

* 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? *

Yes No

If yes please provide details *

Swimming Ability

I can swim 50 metres *

No With a struggle Comfortably Strongly

Sizing

Height (cm) *

Weight (kg) *

Fitness Level

My level of fitness is *

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. *

I accept this declaration

Submit