Resources

MEDICAL FORM - Competitor

ALL INFORMATION PROVIDED IS CONFIDENTIAL

Details

Team/Race Number

Team Name

Race

PursuitPure

First Name

Last Name

Occupation

Email Address

Mobile Number

Home Address

Date of Birth (dd/mm/yyyy)

Age at Race 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

Emergency Contact Phone Number

What is their relationship to you?

Emergency Contact Person’s Address

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?

NoYes

If yes, please specify type, amounts you take, brand name and the most important cause of taking these.

Are you allergic to any medications?

NoYes

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?

NoYes

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)

NoYes

If yes, please list:

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?

NoYes

If yes, will you have spare lenses or glasses?

NoYes

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 certify that I am physically fit, have sufficiently trained for participation in the GODZone Adventure Race, and have not been advised otherwise by a qualified medical person.

• 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 that the information given in this form is true and complete to the best of my knowledge.

I declare