Apply for Course

Address *

Line 1

Line 2

City

State

Zip Code

Country

Race Distance and Discipline *

Previous Experience - please summarise your cold weather experience to date: *

Dietary requirements - please list any allergies, intolerances or preferences: *

1. Are you pregnant? *

Yes No

2. Do you suffer from or ever suffered from back pain or problems including sciatica? *

Yes No

3. Have you undergone major surgery in the past 2 years? *

Yes No

4. Do you suffer from asthma or any breathing related illness? If yes, do you use an inhaler? *

Yes No

5. Do you suffer from diabetes? If so please give details of type and treatment used: *

Yes No

6. Are you on any medication? Please list and state what condition the medication is for: *

Yes No

7. Have you ever had a head injury? *

Yes No

Further Details *

8. Do you have or have you ever suffered from epilepsy? *

Yes No

Further details *

9. Have you ever suffered from any heart problems? *

Yes No

10. Do you suffer from any circulation problems? *

Yes No

Relationship to you *

Any information given here will treated in the strictest confidence and will not be shared with any third parties. The information is to assist us in helping course delegates in the event of a medical emergency. The information will be kept confidential between the delegate and the course tutor and support staff.

Declaration

This information is true and correct to the best of my knowledge and I take full responsibility for my actions. I understand that the activity I am undertaking with Survive2Race is inherently dangerous and could pose a risk to my health, however I understand Survive2Race will reduce any risk and manage any situation within my best interests.

Signed - type full name here *

Apply to become a finisher

Application form

Medical Questionnaire

Emergency contact details

Declaration