Hack the Burgh Medical Information Form
Your Details
Please fill all those details, failure to do so might deny your admission on the day
Full Name *
Medical Information
Doctors Surgery *
Doctor's Name *
Phone Number *
Address *
Any Known Medical Conditions
Any Regularly Taken Medication?
Do you give consent for us to provide emergency medical care? *
Do you give consent for an appropriate medical practitioner to give emergency aid to you/your child. If under 18 in the absence of a parent or nominated other a member of staff will be present while the care is provided. You cannot attend the event if you do not give consent.
Primary Emergency Contact
Primary Emergency Contact *
Home Phone Number *
Mobile Number *
Secondary Emergency Contact
Secondary Emergency Contact
Home Phone Number
Mobile Number
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