Form for 1 person Back Personal information Title * MsMissMrsMr First name * Last name * Date of birth * Is your birthday during the walk? * YesNo Emergency Contact * Emergency contact name * Emergency contact phone number * Emergency contact email * Relationship to you * Medical History According 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 * YesNo Do you have any allergies to medications? * ---YesNo Please specify * Do you have any disabilities, medical conditions or injury that may impact your bushwalking participation? * ---YesNo Please specify * Are you taking any medication? We should know in case of emergency. * ---YesNo Please specify * Dietary Information Do you have a good appetite? * ---SmallMediumBig Do you have any dietary requirements or food allergies? * ---YesNo Please specify * Can you tolerate some small amount of the specified food? * YesNoNot applicable Fitness Level Please, rate your fitness level. * Below averageAverageAbove averageExcellent Swimming * 100 metres unaided300 metres unaidedNone swimmer Are you a member of a bushwalking club or walking group? * YesNo How often do you exercice (bushwalking, running, sport...)? * DailySeveral times per weekWeeklyOther Have you already done a multi-day bushwalking trip? * ---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...)? * ---YesNo Please specify. * Have you already walked off track? * ---YesNo To 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) Miscellaneous Can you assist with driving? * YesNo Do you give permission for us to use images of yourself for promotional materials? * YesNo Do you have your own transport? (optional) YesNo Do you have a first aid certificate? (optional) YesNo Where did you hear about NoTraces Bushwalking Australia?