Trainee Medical Information And Consent Form

(Fill out one form for each trainee)

Personal information

Your Name (required)

Your Address

Your Phone Number

Your Email (required)

Your Date Of Birth

Your Weight (kg)

Your Height (cm)

Your Sex
 Male Female

Medical information

Please answer the following questions to the best of your ability. The activities you will participate in are often of a different physical nature than most participants are used to. All medical concerns need to be known. If you have questions regarding your participation, we encourage you to consult your physician.

Do you or have you ever suffered from any of the following?

If yes, please tick.

 Asthma Allergies Allergic to Insect Bites Back Problems Cerebral or Pulmonary Edema Diabetes Dislocations Eyesight ;-Glasses/contact lenses Eyesight: Colour blindness Heart Problems High Blood Pressure Hearing Problems Currently under doctor’s care Taking Medications Limitations to Your Activities Pregnant

Describe any of the suffered medical conditions you ticked:

Do you have a medical condition not listed above that we should be made aware of? Yes No (please circle)

If unsure, please inform us.

Will you consume alcohol or drugs 24 hours prior to your lesson? (If unsure inform us)
 yes no

if yes give details

In case of emergency please notify:




Phone Number:

Evening Phone Number:

General Information and Declaration


The activities that you will encounter are of physical nature.

Participants are expected to be competent swimmers (floatation vests are provided if you are unsure about your


If you feel you have any physical disabilities that might affect your safe participation, inform your instructor.

Participants are also expected to be able to communicate proficiently in English.

Type below "I -INSERT-YOUR-NAME-HERE- have read and understand the General Information and Declaration above" (copy and paste ADDING IN YOUR NAME to make things quicker)

Click Submit

Approved by: Jefferson Hunter Issue Date 17/10/14 Version 1