Medical Check FormAny information collected here is gathered for safety reasons, is sent to a secure server in strict confidence and is never shared with a third party. Contact InformationName* First Last Email* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Date of Birth* MM slash DD slash YYYY Phone*Medical InformationHave you ever been advised by your GP not to exercise?* Yes No Do you have a history of heart problems?* Yes No Do you have high blood pressure/dizziness or lose consciousness?* Yes No Do you have back pain or injury?* Yes No Do you have pain or limited movement in any joints?* Ankles, knees, hips, etc... Yes No Please Specify:* Have you been diagnosed with osteopenia or osteoperosis?* Yes No Do you have epilepsy?* Yes No Do you have diabetes?* Yes No Do you smoke?* Yes No Are you pregnant or do you have a child under 6 months?* Yes No Are you taking any prescribed medications?* Yes No Do you know of any other reason why you should not engage in physical activity?* Yes No Please Specify:* Are you taking any prescribed medications?* Yes No Can you Swim?* Yes No If you have had any surgical proceedurs, injury, chronic illness or other medical condition please give details here:-Declaration* I declare that I have answered all the questions on this form honestly and that I have not withheld any pertinent health or medical information.How Did you Hear About Us?*--Please Select--Google SearchFacebook PageFriend ReferralFacebook AdReferral from Kayaking ClubOtherPlease Specify:* Consent* I agree to Booking Terms and Conditions & Privacy Policy.If you are under 18 your parent or guardian must give permission for you to attend any activity organised by Kayaking.ie. You parent our guardian must also confirm that he/she has accepted our terms and conditions Parent or Guardian to Tick Box to Confirm Permission and To Confirm Acceptance of our Terms and Conditions and to Verify Medical InformatiomName and Contact Number of Parent or Guardian* Δ UNFORGETTABLE KAYAKING EXPERIENCE WE HAVE A RANGE OF COURSES & CLASSES FOR INDIVIDUALS, GROUPS & FAMILIES BOOK NOW
