Risk and Medical Disclosure form

Please complete the below confidential form.

Full name

Do you have any medical conditions that we should know about? (Asthma, allergies, physical disabilities)

Are you taking any medication? If so, please note:

Is there anything else we should know to help us keep you safe? (e.g. recent injuries or niggles)

HAZARD/RISK/DANGER DISCLOSURE ACKNOWLEDGEMENT I acknowledge and fully understand that there are inherent hazards/risks/dangers, both known (listed below) and unknown, involved with this activity and the environment within which it will occur. I am aware of the implications of participating in this activity and the environment within which it will occur, and the consequences of my actions should I ignore NATURE AND NOSH TOURS safety management procedures and directions and I accept full responsibility for my own actions, inaction, negligence or unacceptable behaviour at all times while on this tour. I acknowledge and understand that, other unknown or unanticipated risks and hazards may arise due to the nature, natural circumstances and or climatic conditions. I acknowledge that NATURE AND NOSH TOURS reserves the right to withdraw any person, who in their opinion, is likely to endanger themselves or others, and to cancel the activity if they become concerned for any reason for my safety or that of any other person, with or without notice. I acknowledge that NATURE AND NOSH TOURS will be taking all reasonable and practical steps to ensure my safety while I am involved in this activity.

IDENTIFIED HAZARDS/RISKS/DANGERS (please check this box when you have read) · Falls · Hypothermia · Dehydration · Hot weather · Cuts/ abrasions · Terrain hazards · Slippery conditions · Stings · High winds · Medical problems · Exposure to sun · Cold weather

Emergency contact name and phone number

TIAKI PROMISE: WHILE TRAVELLING IN NEW ZEALAND I WILL: CARE FOR LAND, SEA AND NATURE, TREADING LIGHTLY AND LEAVING NO TRACE

TIAKI PROMISE: WHILE TRAVELLING IN NEW ZEALAND I WILL: TRAVEL SAFELY, SHOWING CARE AND CONSIDERATION FOR ALL

TIAKI PROMISE: WHILE TRAVELLING IN NEW ZEALAND I WILL: RESPECT CULTURE, TRAVELLING WITH AN OPEN HEART AND MIND

Address

Thank you for submitting your Risk and Medical disclosure form.

Risk and Medical Disclosure Form

Please complete the below confidential form.

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