MEDICAL DETAILS, consent AND acknowledgement of risk

Each person must complete this form prior to attending a trip organised by Primal Adventures. A parent or guardian must complete this for anyone under 18 attending a Primal Adventures trip.  

Please see our Privacy Policy as an assurance that any personal information will remain confidential. 

PERSONAL & MEDICAL INFORMATION

All fields marked with an * are compulsory

Name *
Name
Address *
Address
Date of Birth *
Date of Birth
Please provide name, relationship to you & phone number
E.g. vegetarian, vegan, gluten free
cms
Kgs
Has your doctor ever told you that you have a heart condition or have you ever suffered a stroke? *
Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise? *
Do you ever feel faint or have spells of dizziness during physical activity/exercise that causes you to lose balance? *
Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months? *
If yes, you will need to provide an Asthma Action Plan from your Doctor, and all medication
If you have diabetes (type I or type II) have you had trouble controlling your blood glucose in the last 3 months? *
Do you have any diagnosed muscle, bone or joint problems that you have been told could be made worse by participating in physical activity/exercise? *
Do you have any other medical condition(s) that may make it dangerous for you to participate in physical activity/exercise? *
For example pregnancy, recent surgery or any other recent or ongoing medical conditions
Please provide any details here
Do you have any allergies? *
If you have had an anaphylactic reaction, you will be required to complete an additional form
Do you have a family history of Heart Disease? *
E.g. Stroke, heart attack
Frequency/week, intensity, duration
Do you currently have a diagnosed mental illness, or have you recently had a period of mental ill health? *
Severity, duration, treatment, triggers
Do you currently take any medication? *
Do you smoke, or have you quit in the last 6 months? *
If you are aged over 55, you are required to have passed a complete physical examination in the last 12 months *
CONSENT AND ACKNOWLEDGEMENT OF RISK *
The Primal Adventures trip is being organised by Primal Adventures, ABN 9387 065 8696 PLEASE READ THIS DOCUMENT CAREFULLY BEFORE AGREEING 1. I understand that participating in the PRIMAL ADVENTURES TRIP that I have booked into (“the Trip”) involves walking on roads and paths, uneven surfaces and taking part in exercise. I am aware of the hazards involved. The hazards include, but are not limited to, road or track surfaces, remoteness from assistance or medical aid, the strenuous nature of exercise and carrying a pack, becoming lost, vehicle traffic, actions of participants, general public, organiser’s personnel, supporting agencies, weather conditions, heat exhaustion, condition or suitability of participant’s clothing, footwear or equipment. In my judgment I have sufficient competence and experience to participate safely in the Trip. 2. I certify that I am physically fit, have sufficiently trained for participation in this event and have not been advised otherwise by a qualified medical person. I have completed all medical details accurately and disclosed any medical conditions. 3. On behalf of myself, my executors, administrators, heirs, next of kin, successors and assigns, I: a. RELEASE AND DISCHARGE; Primal Adventures and each of the Trip leaders, assistants, community organisations and all State, Federal and Local Government authorities with responsibility for the locality in which the event may be staged and their or its respective officers, directors, employees, independent contractors, representatives, agents and volunteers (Indemnified Parties) from any and all liability for death, disability, personal injury, property damage, property theft and all other loss or injury whatever and however occurring which I may suffer as a result of or in connection with, directly or indirectly, my participation in and my travelling to and from this event and I waive all and any claims against the Indemnified Parties which but for the execution of this Acknowledgement Waiver and Release I may have had against the Indemnified Parties or any of them; b. INDEMNITY AND HOLD HARMLESS the persons or entities mentioned in paragraph 3a from any and all liabilities, claims or actions (including negligence) whatever or however caused which may be brought against them or any of them arising as a result of or in connection with, directly or indirectly, my participation in and travelling to and from this event. 4. I hereby consent to receive medical treatment which may be deemed necessary in any event of injury, accident and or illness during the Trip. I acknowledge that I have obtained the relevant insurance cover for the duration and location of the Trip. 5. I agree to abide by the Trip rules and I understand that my participation may be voided if through my actions or behaviour, in the opinion of the organisers, I break any of the rules or I bring the Trip into disrepute. 6. I give my consent for any photos, video or other promotional material to be used by Primal Adventures on their website, Facebook page or for any other marketing purpose. If I do not consent to this, I will inform the organisers. 7. In selecting YES, I acknowledge that I am signing for either myself, or my child if under 18. I also acknowledge that myself or my child has been cleared by a Doctor to participate in strenuous exercise if we have any medical conditions.

Thank you for providing the information. We look forward to seeing you out on the trail!