health form – re-wild

Name*

Prefix First Last

Detail any current and/or previous medical conditions, physical disabilities and learning difficulties you have that might affect your performance/safety on your experience?*

Detail of any other conditions requiring medical treatment*

List any current prescribed medication*

Do you have any known allergies including medications, plasters & food?**

Yes
No

Please give specific details*

Details of any other special needs you have (including dietary)

If you were injured or became unwell and required an emergency hospital attendance: Who should Jay contact on your behalf?*

First Last

What is the best phone number to contact them on during the day?*

What is the best phone number to contact them on at night?

Who is your next of kin?*

First Last

What is the best phone number to contact them on during the day?

What is the best phone number to contact them on during the night?

What is the name of your doctor's surgery?*

What is your GPs telephone number?*

What is your NHS number?

Consent

I give my consent for still & moving digital images to be taken of me whilst participating in the booked experience

Promotions

Check this box if you would like re-wild to contact you about promotions and future events (please send an email to: re-wild.co.uk if at any point in the future you no longer wish to receive these promotional emails)

Health and Personal Information Form