Survive to Race
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Application form
Please complete the application form and and then submit to apply for a place on Survive to Race 2021. Once we receive your form we will get in touch as soon as possible.
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Indicates required field
Name
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First
Last
Address
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Line 1
Line 2
City
State
Zip Code
Country
Email
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Phone Number
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Occupation
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Race Distance and Discipline
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Previous Experience - please summarise your cold weather experience to date:
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Dietary requirements - please list any allergies, intolerances or preferences:
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Medical Questionnaire
1. Are you pregnant?
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Yes
No
2. Do you suffer from or ever suffered from back pain or problems including sciatica?
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Yes
No
Further Details
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3. Have you undergone major surgery in the past 2 years?
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Yes
No
Further Details
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4. Do you suffer from asthma or any breathing related illness? If yes, do you use an inhaler?
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Yes
No
Further Details
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5. Do you suffer from diabetes? If so please give details of type and treatment used:
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Yes
No
Further Details
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6. Are you on any medication? Please list and state what condition the medication is for:
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Yes
No
Further details
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7. Have you ever had a head injury?
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Yes
No
Further Details
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8. Do you have or have you ever suffered from epilepsy?
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Yes
No
Further details
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9. Have you ever suffered from any heart problems?
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Yes
No
Further Details
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10. Do you suffer from any circulation problems?
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Yes
No
Further details
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Emergency contact details
Name
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First
Last
Email
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Phone Number
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Relationship to you
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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
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Submit
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