fun_run_2019_entrance_form

2019 fun run entrance form

if you would like to enter the fun run then please complete the following form, there are a lot of questions but we have been advised for our insurance we need to ask them, sorry...

* Indicates required field

name *

First

Last

phone number *

date of birth *

age *

email address *

name of your emergency contact *

relationship *

their contact number *

if any of the following apply then please give details otherwise type no

do you take any regular medication? *

do you smoke? *

are you pregnant? *

do you have high blood pressure? *

do you have high cholesterol? *

do you have diabetes? *

do you have epilepsy? *

do you have history of stroke? *

do you have known heart disease? *

do you have chest or breathing problems? *

do you have asthma? *

any metabolic conditions?(thyroid, kidney) *

do you have lightheadedness or fainting? *

do you have joint pain or arthritis? *

have any current musculoskeletal conditions? *

are you active throughout the week? *

yes no

any other comments *

Submit

to the best of my knowledge, the above information is true and I understand if this information changes at any time, it is my responsibility to advise one of the run leaders, and I also understand that I participate at my own risk

you authorise us to keep your data for the purposes required for running this event, it will not be used for marketing purposes or passed on to other companies