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Contact & Health Declaration Form

                 

'01344 762386     WWW.YellowBirdSailing.co.uk    Email@YellowBirdSailing.co.uk 

Please complete this form as thoroughly as possible. The information provided on this form will be treated

as confidential and is only required on board in order to enable the crew to give appropriate medical help

and support if required.

Trip Date        Your Name 

E-mail Address      Date of Birth

 

Your Address  

 

                  Your Telephone Numbers                                                  Emergency Contact Details

Daytime               Name of contact   

Evening            Relationship to you   

Mobile        Contact's telephone No   

Please provide a mobile number for the morning of the trip.                 Someone contactable ashore for the duration of your trip

 

Medical & Dietary Details

Please tick the appropriate box if the answer to any of the following questions is yes, and provide further details.

Do you have any special dietary requirements?       

Do you have any allergies?       

Do you now or have you ever suffered from Asthma, Diabetes, Dizziness or Epilepsy?        

Are you currently taking any medication?       

Have you undergone surgery or received any medical treatment in the last 6 months?       

Do you suffer from any heart condition?       

Do you have any other medical conditions or physical disabilities?       

Details

Are you pregnant?       

Please note, we do not recommend pregnant women take part in any of our experiences, without consulting their GP.

If you are pregnant please let us know how many months..

 

Please initial in the box below to indicate that you have answered all these questions to the best of your

knowledge   

Once you have completed this form, please select submit to send it to us, or print and post it to the address above.

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