Medical Form

Learner Name

Home Address

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Postcode

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Date of Birth

Emergency Contact Name

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Emergency Contact Telephone Numbers

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Doctors Name

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Doctors Address

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Medical consent:

I consent to receiving any necessary first aid or medical treatment for any injury or illness during the outdoor training course.

Date

Do you suffer from any of the following:

	Yes	No
Allergies (including medication, plasters, stings, pollen etc)
Do you have any dietary requirements (including allergies)
Asthma or breathing difficulties
Diabetes
Sensory Loss (sight, speech or hearing)
Travel Sickness (any medication needed)
Have you received any medical or surgical treatment in the last 3 months?

If you answered 'Yes' to any of the above questions please give further info here:

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Have you...

	Yes	No
been vaccinated against Tetanus in the last 10 years?

Describe any prescribed medication or advice to be followed in an emergency:

0 /

Where The Fruit Is - Social Enterprise Registered as a limited company In England and Wales

Company Number 10832411