Title:
Given Name: (as per passport)
Last Name: (as per passport)
Email Contact:
Phone Contact:
(state home or work)
 
Male or Female?
 
Mailing Address:




Postcode:
Country:
Voyage Choice:
Preferred name/ nickname, if different from above
Date of Birth (dd/mm/yyyy)
Passport Details
Passport Number:
Nationality
Date of Issue: (dd/mm/yyyy)
Place of Issue
Date of Expiry: (dd/mm/yyyy)
Emergency Contact Details of Individual ASHORE
Name
Relationship
Phone contact
Address
Medical Questions
Height (m)
Weight (kg)
Have you ever had epilepsy?
1.
Do you ever faint or have blackout spells?
2.
Do you have diabetes?
(If yes, for how long?)
3.
If you have diabetes, what medication are you currently taking?
3a.
Are you pregnant?
If yes, at what stage?
4.
Have you ever had a major operation?

Please detail

5.
Are you presently being treated by a doctor?
6.
Are you taking any regular medication? Please detail
7.
Do you have high blood pressure?
8.
Have you had angina or a heart attack?
9.
Do you have any back or joint problems ?
10.
Do you have any limiting physical handicap? (including sight/hearing problems
11.
Is there anything else that we should know about that could affect your level of participation on the voyage?
Treatment for mental illness or depression (past or present) must be included
12.
Do you undertake any regular strenuous exercise?
13.
Do you envisage you will be able to help set sails
or climb the rigging ? (not compulsory)
14.
Any dietary requirements? E.g. vegetarian?
15.
Are you allergic or have any known reactions to any foods or medications (e.g. Penicillin)?
16.
I have read agree with the
Terms and conditions

Please type Agree if you agree with the terms and conditions - or Not Agree
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