"*" indicates required fields Name* First Last Age*Email (Required)* Phone*Emergency Contact Name* First Last Emergency contact phone*Emergency Contact RelationE.g. spouse, child, friendDo you have any of the following:Diabetes* Yes No Take insulin?* Yes No Take other medications?* Yes No Please explain your situation / needsThe more detail you provide, the better we are able to provide assistance and care.Do you have any allergies?* Yes No Please explain your situation / needsThe more detail you provide, the better we are able to provide assistance and care.Do you use an epipen?* Yes No Do you carry an epipen?* Yes No Epilepsy* Yes No Heart condition* Yes No Asthma* Yes No Do you use an inhaler?* Yes No Please explain your situation / needsThe more detail you provide, the better we are able to provide assistance and care.Date of your last Tetanus shot* MM slash DD slash YYYY Have you been under a doctors care in last 12 months?* Yes No Please explain your situation / needsThe more detail you provide, the better we are able to provide assistance and care.Any other health conditions we should know about?Fitness* Poor Fair Good Excellent Swimming ability* Poor Fair Good Excellent Do you get cold easily?* Yes No Date* MM slash DD slash YYYY Signature*You can type in your name as proof of signing.Guardian signature if under 19 years oldYou can type in your name as proof of signing.Confirm that you have read, understood, and completed the Magnetic North Sea Kayaking Medical Information Form (Required):* Yes, I have read, understood, and completed the Magnetic North Sea Kayaking Medical Information Form CommentsThis field is for validation purposes and should be left unchanged. Δ
"*" indicates required fields
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