Medical Questionnaire

medical Questionnaire

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Explorer's Details

Name:

School:

Expedition code:

Destination & Year:

Date of birth:

I confirm that my child has the following medical condition:

When was this condition diagnosed and by who?

How does the condition present itself?

What medication does your child use?

Has your child ever required hospital admission for their condition?

If ‘YES' please give details (including dates):

Have you sought advice from your child's doctor or hospital prior to completing this health declaration?

If ‘YES’, what did the doctor/specialist advise?

Do you have any additional comments or declarations to make regarding your child's health?

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Important:

I fully understand that adventurous training is a strenuous activity undertaken in remote areas. Additionally, I confirm that if I am unsure about my child's suitability to take part in this expedition I should seek advice from my doctor or specialist before signing this declaration. Should my child's condition change, before arriving for activities requiring any amendment to the above questionnaire, I will advise the person in charge immediately.

Student signature:

Parent/ Guardian signature:

Date:

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Declaration

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I confirm that the information provided by me is to the best of my knowledge true & correct

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Adventure Lifesigns reserves the right to withdraw participants from the expedition if any information is found to be false.