Delegate Medical Information Form Course Info Course —Please choose an option—Level 3 Qualification in Lowland Walk LeadershipLevel 3 Qualification in Lowland Expedition Leadership2-day Outdoor First Aid Venue —Please choose an option—Felton Village Hall & Local AreaThetfordFelden LodgeBlackwell AdventureLong Mynd Adventure CampSayers CroftPeak District Course Start Date Course End Date Personal Details First Name Last Name Email Address Phone Number Date of Birth Emergency Contact First Name Last Name Phone Number (Day) Phone Number (Evening) Mobile Phone Number Your Address Address Line 1 Address Line 2 Town/City County Postcode Your Doctor's Details Name of Doctor Doctors Phone Number Surgery Address Surgery Name Address Line 1 Address Line 2 Town/City County Postcode Medical Details Details of any medicine/diet/treatment, which is being taken/followed Details of known allergies/sensitivities (e.g. Penicillin) Any Special Dietary Requirements? Do you know the date of your last Anti-Tetanus Injection YesNo Date of last Anti-Tetanus injection (if known) Chase Training Solutions often takes photographs or video film for publicity purposes. These images may appear in our printed publications, on our website, Facebook, Twitter or Instagram accounts. We may also send them to the news media or to sponsors for further publication. May we use your image(s)? YesNo Delegate Signature Parent/Guardian Signature (if the delegate is under 18) Please Note There can be a delay after pressing "submit". Please only press "submit" once and allow time for your details to upload.