Your Details
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First Name
Last Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
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Phone
(###)
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Emergency Contact Details
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First Name
Last Name
Phone
(###)
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Relationship to you
Can you give a brief overview of your current movement? (I.e walking the dog, gym, cycling, swimming, walks with friends)
Do you feel comfortable walking on an incline for at least 2 hours?
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Yes
No
Have you had any major illness or injuries in the last 3 years?
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Yes
No
If YES, please provide as much detail as possible.
Are you currently taking any medication or receiving treatment for any medical conditions?
Yes
No
If YES, please provide as much detail as possible.
Do you have any existing medical issues that are currently self-managed? (i,e without medical prescription)
Yes
No
If YES, please provide as much detail as possible.
Are you allergic to any medication?
Yes
No
If YES, please provide as much detail as possible.
Do you have any existing injuries/aches/niggles? Or any sign of minor injury?
Yes
No
If YES, please provide as much detail as possible.
Which re:treat are you attending?
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Italian Dolomites: 19 - 24 September, 2024
Lake District Weekend: 1 - 3 November, 2024
Another Place Hotels: 7 -10 October, 2024
Lake District Weekend: 14 - 16 March, 2025
Tuscany: 15 - 19 May 2025
Please select today's date.
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