Hiking Participant Information Form - The Real Girls Movement

Hike fit – Full Day Hike

Hiking Participant Personal Information

This form is designed to disclose any pre-existing injury or condition that you have suffered of which you are aware, and which you could reasonably foresee could be affected by participation in the scheduled activity. The Real Girls Movement may require, after reviewing this information, that you visit a doctor to gain approval to participate in the activity. This will be determined after this form is received by The Real Girls Movement and in consultation with you. The information requested is also used to determine participants' current hiking capabilities and skills. All private information on this form will remain confidential and only be shared with relevant staff to ensure participant care and safety whilst on the scheduled activity.

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Your Personal Information

The Real Girls Movement will use this information if you are involved in a medical emergency. All information is held in confidence. The medical information on this form must be current when the activity is run. You are responsible for all medical costs if you are injured on a The Real Girls Movement approved activity unless The Real Girls Movement is found liable (liability is not automatic).

Your Name(Required)

First Last

Date of Birth(Required)

Day

Month

Year

Your Email Address(Required)

Enter Email Confirm Email

Address(Required)

Street Address Address Line 2 Suburb State Post Code

Your Phone(Required)

First Emergency Contact

First Emergency Contact Name(Required)

First Last

Relationship(Required)

Phone(Required)

Second Emergency Contact

Second Emergency Contact Name(Required)

First Last

Relationship(Required)

Phone(Required)

Medical Information

Health Conditions(Required)

Please tick if you are living with any of the following health conditions: (Please provide a management plan or provide details for any conditions you tick)

Asthma

Diabetes (Type 1 or 2)

Heart Condition

Epilepsy/Seizures

Blackouts

Sleep Walking

Travel Sickness

Anxiety/Panic Attacks

Cardiovascular System (e.g., heart /circulation)

Muscular Skeletal Issues (e.g., muscles, bones)

Any disabilities / conditions that staff need to be considerate of or which you may need assistance (e.g., sight/hearing)

Conditions that alter your alertness, e.g., migraines, chronic back pain

No existing health conditions

Existing Health Conditions not listed above

Injuries & Pre-Existing Physical Conditions

Past injuries & pre-existing physical conditions(Required)

Do you have any past injuries pre-existing physical conditions at all (particularly ones which may be affected by walking long distances, up and down slopes on uneven ground, carrying a heavy pack for extended periods of time)? If yes, provide further details below.

Yes

If you ticked yes to past injuries or pre-existing physical conditions above please provide further details.

Are you ever affected by conditions that alter your alertness (e.g., migraines, chronic back pain)?(Required)

Yes

If you ticked yes to conditions that alter your alertness above please provide further details.

Allergies

Allergies:(Required)

Please tick if you are living with any of the following allergies (Please provide a management plan or provide details for any conditions you tick)

Medication

Food

Other (please detail below)

No known allergies

If you have ticked a known allergy ticked above :

Tick all that apply and provide further detail below.

the allergy is anaphylaxis

you carry an EpiPen at all times

you require other medication for your allergy

Please provide details or management plan if you have ticked any of the boxes relating to allergies.

Medication

Are you taking any medication(s)?(Required)

If yes, provide further details below.

Yes

If you ticked yes to medications above please provide further details.

Please provide details of medication name, dose, when, how and why it is taken. Does it have any restrictions? e.g., advised not to use machinery, causes fatigue.

PERSONAL AUTHORISATION AND DECLARATION(Required)

PARTICIPANT BEHAVIOUR

I understand that in the event of my misbehaviour or behaviour that poses a danger to myself or others during the activity, my participation in the activity may be halted and I may be required to leave.

I further understand that in such circumstances that any costs associated with my return home will be my responsibility.

MEDICAL CONSENT

Where the supervisor in charge of the activity is unable to contact my emergency contact, or it is otherwise impracticable to contact them, I authorise the supervisor in charge to:

- Receive any medical or surgical attention deemed necessary by a medical practitioner.
- Administer such first-aid as the supervisor in charge judges to be reasonably necessary.
- I give permission for the Real Girls Movement to pass this information to a third party (e.g., Doctor, hospital) to facilitate medical treatment. Personal information may also be disclosed to the relevant authorities under the Accident Compensation Act, including but not limited to Victorian Workcover Authority and employers Workers Compensation insurance provider.

PARTICIPANT ILLNESS

I understand that in the event activity staff determine it is necessary for me to be sent home early due to illness, any cost associated with my return will be my responsibility.

CANCELLATIONS OR ALTERATIONS

I understand that The Real Girls Movement may need to cancel or alter excursion arrangements at short notice, for safety reasons or due to circumstances beyond their control, and every effort will be made to try and minimise inconvenience or financial losses to me, these may be unavoidable.

PARTICIPANT ACCIDENT INSURANCE AND AMBULANCE COVER

The Real Girls Movement does not provide participant accident insurance or ambulance cover. You may wish to obtain accident insurance from a commercial insurer and/or ambulance cover, depending on their health insurance arrangements and any other personal considerations.

I declare that I have read and understood the questions and the purpose of this form and that the information provided on this form is complete and correct and that I will notify Real Girls Movement if any changes occur.

Signature(Required)

In signing this Waiver, I certify that I have read this document and that I fully understand its contents and the consequences of participating in the Activities. I am aware that this is a release of liability and a contract and I sign it of my own free will.

Name(Required)

First Last

Date(Required)

Day

Month

Year

Hike fit – Full Day Hike

Hiking Participant Personal Information

Your Personal Information

First Emergency Contact

Second Emergency Contact

Medical Information

Injuries & Pre-Existing Physical Conditions

Allergies

Medication

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