Name * First Name Last Name Email * Home address * Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency contact name * Emergency contact relationship * Emergency contact phone number * (###) ### #### Alternative emergency contact phone number: * (###) ### #### Date of birth * MM DD YYYY Gender * Doctors name * GP address * Address 1 Address 2 City State/Province Zip/Postal Code Country Have you ever suffered from? (please tick those applicable) * Asthma Epilepsy Diabetes Heart condition None of the above Have you been vaccinated for tetanus? (If yes, please give the date of the last injection and if the booster dose has been given) * Do you have any other medical condition requiring regular treatment or likely to make medical treatment necessary? * Do you have any allergies? * Please specify any dietary requirements? (please tick those applicable) * Vegeterian Vegan Dairy/Lactose intolerant Egg allergy Wheat/gluten intolerant Peanut/nut allergy Fish/shellfish allergy None of the above Other (please specify) Medical consent * By ticking the below box, I agree to participating in the residential trip and understand the nature of the activities undertaken. I agree to receiving medical and dental treatment being given if required, including the administration of a general anaesthetic and to surgical operations in case of emergency, in accordance with the recommendations of a qualified medical practitioner. Yes No Film & photography consent * Black Girls Hike and YHA may undertake filming and photography during the weekender. By ticking "yes" the below box, I agree to take part in Black Girls Hike and YHA filming and photography projects and understand that the images/video footage will be used and stored in accordance with Black Girls Hike and YHA’s Privacy Policy and GDPR. Yes No Thank you!
