Medical Declaration Form Medical Declaration Form Booking ID * Date of Event From Turitop Name of School / Group Name School Address Leader/Teacher/Parent Name * Leader/Teacher/Parent Name First First Last Last Your Email * Group leaders please use the email address used when booking if you are signing on behalf of a group Your Phone Number * How will this medical declaration cover your group? * Group leader signing on behalf of all attendees in the group Share medical declaration with parents/legal guardians of attendees Who is covered by this medical declaration * I am signing this declaration on my child's behalf Child's Name Child's Name First First Last Last It should be understood the activities and courses you have selected for your group involve a certain amount of physical and mental exertion. If any members of your group have any of the following medical conditions or conditions please make us aware of them in the box provided below. Please note that should they have any of the following medical conditions we advise they do not take part in the relevant activities. These conditions include, but are not limited to, the following: Heart disease/chest pain High or low blood pressure Epilepsy, fits, blackouts Difficulty with balance & Coordination Fear of heights (for Zipline & Climbing Wall only) Impaired limb function Bad back, strains & sprains Pregnancy Alcohol or drug dependence A recent break or sprain (in last 6 months) A medical or psychiatric condition that you are advised to not take part in physical activities at height or due to their level of physical exertion If any of the conditions listed above apply to any member of your group or they have other medical conditions that you think will by an issue while participating in our activities, we request that you inform their legal guardian that they should speak to your GP and ask for advice and if necessary, to obtain a consent letter or medical fitness form. We ask that you outline if you/any of the participants under your care have had a recent break, sprain, injury or a medical condition including surgeries we need to be aware of in advance of their day. IF YOUR CHILD (OR THE CHILD IN YOUR CARE) HAS ANY OF THE ABOVE CONDITIONS OR A RECENT INJURY UNLESS OTHERWISE STATED WE WILL TAKE YOUR SUBMISSION OF THIS DOCUMENT AS CONFIRMATION THAT THEY HAVE BEEN SIGNED OFF BY A DOCTOR TO PARTICIPATE IN ALL ACTIVITIES AND ARE BACK PLAYING SPORT AND IN NO PAIN OR RISK OF FURTHER INJURY BY PARTICIPATING IN ALL ACTIVITIES FOR THE DAY.IF THEY HAVE BEEN NOT BEEN SIGNED OFF BY A MEDICAL PROFESSIONAL PLEASE STATE THIS BELOW IN THE BOX PROVIDED Please outline if any members of your group have/require any of the following: Recent breaks or sprains Asthma or need to use an Inhaler Epipen Physical Allergies Behavioural or Attention needs Heart condition Any of the conditions listed in the section above Please outline if any members of your group/child have any of the listed conditions or anything else that would prevent them from taking part none After Clicking Submit, please scroll to the bottom of the next page to sign the form. Submit If you are human, leave this field blank. Δ
