Medical Survey

These questions will help us gather information about you, prepare you for the Giant Walk and keep you safe and informed. Each participant needs to compete this form:

Choose your event

1. Which event are you signing up for?

Contact Details

2. Full Name (as it appears on your passport).

3. Your Address.

4. Your Email.

5. Mobile Number.

6. Date of Birth.

Emergency Contact (cannot be someone on the walk)

7. Full Name.

8. Relationship to you.

9. Mobile Number.

Medical Conditions

10. Do you have any of the following.
Known AllergensDietary Requirements (e.g. kosher, vegetarian, vegan)Medical ConditionsMedical History relevant to undertaking a walk such as thisMedical Devices that you wearRegular PrescriptionsDisabilities or impairmentsMedication that needs to be carried with you at all timesA condition that would require the consent or approval of your GP to participate in this TrekNone of the above

11. If you answered yes to any of the above, please provide full details in the box below, which will be treated confidentially. We may then need to discuss your personal needs or reassess your suitability for the walk, or check with your/our insurers before confirming your place.

Groups

12. Are you planning on walking with friends or in a group?
YesNo

13. If yes, can you provide a nick-name or group lead you will all be using so we can start/finish you together as best as possible.

General

14. Group formation and Timing: What time do you normally walk 5 kilometers.

15. How did you hear about us?

Training and Information

Here you will need to confirm your understanding of the event preparation, information and risks.

16. By its definition an endurance walk that involves long distances is not without its risks which can be mitigated by planning. Information for this walk will be provided on the event guide before the walk
I have been/am training medium to long distance walking (training guides available in the event guide)I will be prepared to undertake the walk by the start date and suitably equippedI intend to take the longer routes on the day, but I understand I may be asked to undertake a shorter routeI am a qualified trek leader, or outdoor/mountain leader or first aider, and am prepared to assist the trek leadersI understand that the event/group leader's decision on the day regarding my group/safety/fitness or timing is FINALNone of the above

17. To reconfirm you have fully read and considered these above declarations, please enter into this box the number of KILOMETERS in a HALF MARATHON.

Event Risks and Planning

18. By its definition an endurance that involves long distances is not without its risks. Please confirm the following:
I understand the risks involved in trekking and will be responsible for my own actionsI have had*/will take the opportunity to evaluate the Trek's Risk Assessment and will inform Regenesis if there are any additional considerations that will need to be made to accommodate me. *Risk assessment available upon requestI understand that I may not meet time check points on the Trek, and may be moved ahead by vehicle in order to remain connected to the main groupsI have had/will take the opportunity to read the Regenesis General Terms and Conditions, Trek Insurance Policy and Privacy PolicyI will inform Regenesis of any change to my circumstances

19. To reconfirm you have fully read and considered these above declarations, please enter into this box the Emergency Services Phone Number.

20. Please confirm the following:
I will remain responsible for the actions and behaviour of my child