Name: Date Of Birth: Please answer all questions honestly. This will enable us to successfully complete a risk assessment to help safeguard your welfare. Have you ever suffered or currently suffering from the following?
Fainting, Blackouts, Epilepsy Or Fits
SELECTYESNO
Eczema or skin trouble
Heart trouble or high blood pressure
Joint, ligaments or tendon trouble
Claustrophobia or vertigo
Difficulty in climbing stairs
Difficulty in writing
Diabetes
Back pain
Asthmatic Attacks or chest problems
Arthritis, rheumatism or gout
Difficulty in standing for long periods
Mental / emotional illness
Have you been explained the details of the course requirements? SELECTYESNO
Do you understand the physical requirements of the course? SELECTYESNO
If you answered yes to any of the above questions give details(if you have not answered yes, please enter NONE):
On signing this is agree that all information has been provided honestly and have declared any medical issues both physically and mentally.
Signature:
