The Push 2024 Medical Form

Please complete this medical form as thoroughly as possible. This data will be used in case of a medical emergency during The Push 2024 challenge. Your data a will be stored securely, and will be removed once the challenge is over.

"*" indicates required fields

Name*
Next of Kin Name*
Next of Kin Address*
Doctor/GP Address*
Please give details of any medical conditions you have (eg. Asthma, Diabetes, Epilepsy, Autonomic Dysreflexia).
Please give details of any medical treatment/support you are currently receiving, including any prescribed dressings or medication, dosage and frequency.
Please give details of any allergies.
Please give details of any emergency procedures (eg. Epipen).
Please give details of any special dietary requirements.
Your Declaration*