NUIGMC Medical & Declaration Form 2018/2019
This form is to store information important to ensure your safety when participating in club activities. It must be completed by every person taking part in club activities. If you have any questions at any point, please feel free to ask a committee member for help.
Personal Details
Full Name *
Your answer
Student/Staff ID *
Your answer
Current Address *
Your answer
Nationality *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Phone Number *
Your answer
Next of Kin / Emergency Contact
Please provide the details of someone we could contact in the case of an emergency.
Next of Kin Full Name *
Your answer
Next of Kin Contact Number *
Your answer
Relationship to You *
Your answer
Physical Description
Please provide a few distinguishing details about yourself that could assist in the event of an emergency.
Height *
Your answer
Eye Colour *
Your answer
Hair Colour *
Your answer
Medical Details
Please provide details of any relevant medical conditions.
Do you have any of the following? *
Yes
No
Asthma
Diabetes
Epilepsy
Any form of Heart Condition
Further Details
If you answered "yes" to any of the above, please provide any relevant details. Please also provide detail on any other relevant medical conditions.
Your answer
I acknowledge receipt of a copy of the Club rules and agree to be bound by them. I accept that Mountaineering/Hill Walking/Climbing is an activity with danger of personal injury or death. I am aware of, and shall accept these risks, and wish to participate in these activities voluntarily and shall be responsible for my own actions and involvement. I understand that if I have any issue with the above statement that I will make my concerns known to a committee member immediately. *
Required
Data Protection
I hereby give consent that the NUIG Mountaineering club will store the information I have provided in accordance with their data protection guidelines. If I have any concerns, I will make them known to a committee member immediately. *
Required
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