Hikeit 2017 Participant Entry Form

 

Personal Details

Your Name (required)

Age (required)

Date of Birth (required)

Phone Number (required)

Your Email (required)

Next of Kin (required)

Emergency Contact Number (required)

Support Team Details (24-Hour Challenge Only)

Names

Contact Number (24-Hour Challenge Only)

Car Registration (24-Hour Challenge Only)

Team Name/Company

Chosen Individual/Team Charity

Has your doctor or any other healthcare professional ever given you reason as
to why you cannot participate in this event, including events involving altitude
and sudden changes in weather. (required)

NoYes

Will you be participating in any diving activity 1 week prior to the event? (required)

NoYes

More information

Do you have any allergies that we should be made aware of to insure your
safety? (required)

NoYes

If yes list below

From the list below, please initial each box and circle the appropriate option.
Have you ever experienced or have the following:

No Known Medical ConditionsBack or neck pain/injury in the past 2 yearsCoronary conditions Angina/MI/otherDiabetes type 1 type 2Respiratory condition Asthma/ pulmonaryoedema/COPD/otherFits or convolution of any kindHypertension/ HypotensionOther relevant conditions

More information

Are you on any medication including blood thinners e.g. aspirin or warfarin. (required)

NoYes

If yes list below

The information I have provided within the medical questionnaire is correct to
the best of my knowledge.

I Agree

Event Disclosure

Hillwalking and mountaineering are activities with a danger of personal injury or
even death. Those participating in such events should be aware of the risks and accept the responsibility for their own actions and involvement. No responsibility can be accepted by the Red Rox Events & Fundraising or any other parties involved in
the organization or coordination of the event for any incident to yourself or a member of your team.

I hereby declare that I am physically fit enough to participate in Hikeit 2017 and agree to the terms and conditions of the above disclosure. (required)

I Agree

Use of Filming and Photography Disclosure

On previous years we have filmed the event and would like to continue to do this. If
you would like to contribute your film and footage to the final amateur documentary
please state below and provide all footage on a USB stick. A member of Red Rox Events and Fundraising will provide you with a postal address, USB sticks will be returned to sender after footage is copied.

YesNo