The Fly Program Ltd.Medical Form DATE OF PROGRAM, OR EVENT:(Required) MM slash DD slash YYYY PARTICIPANT NAME(Required) PARTICIPANT EMAIL(Required) Retreats can involve trekking, fishing and mountain biking over extended periods of time. You will need a good level of fitness and good health. Suggested preparation: 45 minutes of aerobic exercise (eg: either cycling or jogging/walking) 3 to 5 times a week for 1 month prior to your trip. As you may often be hours from medical help other than our trained staff and first aid kits it is important that only able people participate on these trips. We require that all participants complete the following questions accurately. This information is important and has been invaluable in the past. We ask for your kind co-operation in these matters and invite you to email our team info@flyprogram.org.au should you have any queries. It is important that we are alerted to any special medical needs of our participants. Anything relevant in your medical history will go with your group leader and then be destroyed. Fitness Reasonable Average Good Excellent (An idea of reasonable fitness is the ability to walk over rough ground with a daypack for 7 hours with only short stops)IF THE ANSWER IS “YES” TO ANY OF THE FOLLOWING QUESTIONS, PLEASE SUPPLY FULL INFORMATION FURTHER DOWN THE FORM1. Raised blood pressure?(Required) Yes No 2. Joint or Mobility problems in last 12mths?(Required) Yes No 3. Heart or circulatory disease?(Required) Yes No 4. Chest /lung disease?(Required) Yes No 5. Diabetes?(Required) Yes No 6. Epilepsy/neurological problem?(Required) Yes No 7. Digestive or bowel disorders?(Required) Yes No 8. Asthma?(Required) Yes No 9. Surgical operations in the last 12 months?(Required) Yes No 10. Mental Health conditions?(Required) Yes No 11. Any other problems?(Required) Yes No AGE(Required) HEIGHT(Required) WEIGHT(Required) SHOE SIZE(Required) DOCTOR/MENTAL HEALTH PRACTITIONER DETAILS: DETAILS / LIST OF MEDICATION / ALLERGY TO DRUGS, CHEMICALS OR FOOD:EMERGENCY CONTACT DETAILSWe ask for your kind co-operation in these matters and invite you to email our team info@flyprogram.org.au should you have any queries. It is important that we are alerted to any special medical needs of our participants. Anything relevant in your medical history will go with your group leader and then be destroyed.Emergency Contact Name:(Required) Address(Required) Mobile Number(Required) Email(Required) Date of Activity(Required) MM slash DD slash YYYY Consent(Required) I confirm that I have been requested by The Fly Program Ltd. to complete a medical form to qualify my physical and mental fitness for my forthcoming program. I confirm that the information provided is true and accurate and agree to it being shared with the facilitation team. I confirm that The Fly Program Ltd. will bear no liability should a medical matter arise that I have not disclosed on my medical form and that I shall be financially responsible for any consequent medical expenses. I acknowledge that the The Fly Program Ltd. terms and conditions of contract specify that my doctor must complete this form if I have a pre-existing medical condition (indicated YES to any of the questions above). Pre-existing medical conditions: If you suffer from asthma, high blood pressure/heart disease, diabetes, epilepsy or mental illness; please discuss it with your doctor before your trip.CAPTCHA
