Form for 1 person Back Personal informationTitle * MsMissMrsMrFirst name * Last name * Date of birth * Is your birthday during the walk? * YesNoEmergency Contact *Emergency contact name * Emergency contact phone number * Emergency contact email * Relationship to you * Medical HistoryAccording to the Booking Conditions, if you are 65 years old or over, you will be required to provide a medical certificate. Do you have a medical certificate?*YesNo Upload your document Tetanus inoculation * YesNoDo you have any allergies to medications? * —Please choose an option—YesNo Please specify * Do you have any disabilities, medical conditions or injury that may impact your bushwalking participation? * —Please choose an option—YesNo Please specify * Are you taking any medication? We should know in case of emergency. * —Please choose an option—YesNo Please specify * Dietary InformationDo you have a good appetite? * —Please choose an option—SmallMediumBigDo you have any dietary requirements or food allergies? * —Please choose an option—YesNo Please specify * Can you tolerate some small amount of the specified food? * YesNoNot applicableFitness LevelPlease, rate your fitness level. * Below averageAverageAbove averageExcellentSwimming * 100 metres unaided300 metres unaidedNone swimmerAre you a member of a bushwalking club or walking group? * YesNoHow often do you exercice (bushwalking, running, sport...)? * DailySeveral times per weekWeeklyOtherHave you already done a multi-day bushwalking trip? * —Please choose an option—YesNo Please list your most recent bushwalking trips (when and where). * Have you done any other non-motorised trip of 5 or more days (cycling, kayaking, canoeing, horse riding...)? * —Please choose an option—YesNo Please specify. * Have you already walked off track? * —Please choose an option—YesNoTo assist us with pack advice and air transport, please provide your weight and height.Weight (kg) * Height (cm) * Weigh of the backpack with gear and food? (optional) MiscellaneousCan you assist with driving? * YesNoDo you give permission for us to use images of yourself for promotional materials? * YesNoDo you have your own transport? (optional) YesNoDo you have a first aid certificate? (optional) YesNoWhere did you hear about NoTraces Bushwalking Australia?
