The Push Medical Form 2024

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*

First Last

Date of Birth*

Next of Kin Name*

First Last

Next of Kin Address*

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Next of Kin Phone*

Doctor/GP Surgery Name

Doctor/GP Address*

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Doctor/GP Phone

Medical Conditions*

Please give details of any medical conditions you have (eg. Asthma, Diabetes, Epilepsy, Autonomic Dysreflexia).

Treatments*

Please give details of any medical treatment/support you are currently receiving, including any prescribed dressings or medication, dosage and frequency.

Allergies*

Please give details of any allergies.

Emergency Procedures*

Please give details of any emergency procedures (eg. Epipen).

Dietary Requirements*

Please give details of any special dietary requirements.

Your Declaration*

The above information is to the best of my knowledge correct and I am not aware of any reason why I am not fit to travel or take part in the activities. I undertake to inform Back Up of any relevant changes in my medical circumstances, and give consent for emergency medical treatment, including anaesthetic, as considered necessary by the medical authorities.

I have read and agree to Back Up's Privacy Policy concerning the use of my data.