MEDICAL FORM - Volunteer
ALL INFORMATION PROVIDED IS CONFIDENTIAL
Details
First Name
Last Name
Email Address
Home Address
Date of Birth (dd/mm/yyyy)
Age at Rate Start
Gender
MaleFemale
Emergency Contact Person
Emergency Contact Phone Number
What is their relationship to you?
Emergency Contact Person’s Address
Emergency Contact Person 2
Questions
Do you have any medical conditions currently and /or have had previously?
NoYes
If yes, please specify what type?
Are you currently taking any medications?
If yes, please specify type, amounts you take, brand name and the most important cause of taking these.
Are you allergic to any medications?
If yes, please list:
Please list any allergies you have and if you are currently being treated for them?
Do you wear a medic alert bracelet or tattoo?
Have you recently experienced or been diagnosed with any of the following?
AsthmaHigh blood pressureMigraineEpilepsyLow blood pressureHeadachesNumbness in limbsDizzinessLoss of hearingNausea/vomitingFainting attacksIrregular heartbeatBlurred visionBlackoutsHepatitis
Have you had any previous injuries? (ie. Spinal injury, ligament damage or reconstruction)
Is there anything else pertaining to your health that we should know about (ie. chance of being pregnant?)
Do you wear contact lenses or glasses?
If yes, will you have spare lenses or glasses?
Name of your current insurance
Name of your doctor
Phone number of your doctor
Your doctor’s work address
Declaration
I declare that the information given in this form is true and complete to the best of my knowledge.
I acknowledge that in accordance with the provisions of the Privacy Act 1993 the following information has been brought to my attention
This form collects personal information about me.
The intended recipients of the information are those staff directly involved with safety and medical on course.
This information is being collected and held by 100% Pure Racing.
The privacy Act 1993 entitles me to have access and request a correction of the information
I declare
