MEDICAL FORM

We prioritize the safety and well-being of our participants during wilderness experiences. As part of our commitment to providing exceptional care and support, we kindly request certain personal information on our medical form. We understand that privacy and data protection are of utmost importance to you, and we want to assure you that we treat your information with the highest level of confidentiality and security.

Please select the RVIVAL Experience you are joining:

First name

Last name

Phone

Birthday

Doctors Surgery (name, address & contact number)

Insurance Provider. Contact Details & Policy Number.

Please outline any dietary requirements and food allergies.

Do you have any allergies (e.g Penicillin, Pollen, Insects, Nuts, Grass):

Do you have any medical conditions? (E.G. Asthma, Epilepsy, High Blood Pressure, Diabetes, Angina):

Please outline any previous hospital admissions which are of relevance to participation in this adventurous activity:

Do you have any recurring joint or back problems?

Let us know about your level of fitness and what you do to keep active:

I can swim confidently in open water

How tall are you in CM?

What is your shoe size? (EU sizes)

I completed this form on the following date:

I agree to the participation statement above, acknowledge that adventerous activities I will be participating in during the experience contain a degree of risk and I have declared any medical conditions that are releveant.

Under 18: (If completeting this form as a parent/guardian) I agree to my child taking part in the activites specified in my experience with RVIVAL and I have declared any medical conditions that are relevant to the experience.

By ticking this box I agree that photographs and videos taken during activities may be used in promotional material by RVIVAL LTd.

Signature

+44 (0)7377 386 811

info@rvival.co.uk

MEDICAL FORM

READY TO DESIGN

YOUR EXPERIENCE?