Name *

Enter your first name and surname

First Name

Last Name

Date of Birth (Month/Day/Year) *

MM

DD

YYYY

Emergency Contact Name *

Enter the first name and surname of the person we should contact in the event of an emergency

First Name

Last Name

Address of Emergency Contact *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Do You Have Any of the Following Conditions?

Tick the box against each that apply to you. Leave unticked if not applicable

Asthma or breathing conditions

Heart condition

Fits, fainting or blackouts

Severe headaches

Diabetes

Mental Health condition

Allergies to any known medication

Any other allergies e.g. food, plasters, latex

Other illness or disability

Any condition that could be affected by physical activity

Taking regular medication

Wear a medical identifier (e.g. pendant or bracelet)

Can you take over the counter painkillers (e.g. paracetamol)? *

Yes

No

Have you received a vaccination against Tetanus in the past 10 years? *

Yes

No

Are you receiving medical or surgical treatment of any kind from either doctor or hospital? *

Yes

No

Have you been given specific medical advice to follow in emergencies? *

Yes

No

Declaration - In Good Health *

I am in good health and I consider myself to be capable of taking part in performance activities with BATS

I am in Good Health

Declaration - Change of Circumstances *

In the event of any illness or medical treatment occurring after the submission of this form and prior to the activity, I undertake to inform the production manager

I will inform the Production Manager about any change in circumstances

Accept Privacy Policy *

I understand and agree that my personal data will be processed in accordance with the relevant Privacy Policy that applies to me.

I accept the Privacy Policy