Medical Declaration Form

• Site conducted:

  Select

• Conducted on:

  Date

• Prepared by:

• Location:
  Address

• Condition being declared:

Medication being taken

• Name (& include copy of medical script):

• Dosage:

• Storage requirements:

• Do you carry/need any emergency medication?

  Yes

  No

• Please give details:

• How are you affected by the condition by normal routine activities?

• How are you affected by the condition during strenuous exercise?

• Have you sought advice from your doctor/nurse about your condition in relation to the activity?

  Yes

  No

• Please give details of comments/advice given:

  Yes

  No

  N/A

• Any additional information/comments which will help you manage your condition during the activity?

• I fully understand that the activities may be strenuous and conducted in environmental conditions such as dust, fumes, extreme temperatures and attitudes that may aggravate my condition. I confirm that I have consulted my doctor if there is any doubt regarding the suitability of the activity or my fitness/ability to take part in the activity. Should there be any change in my condition after signing this declaration, I will inform the officer in Charge of the activity to
  travelling to the activity.

• Signature of participant

  Sign

• Date

  Date

• Date and time of approval

  Date

• Approver's signature

  Sign