HomeYorkshire Three Peaks Medical Form Yorkshire Three Peaks Medical Participation Form Name* First Last Telephone*Emergency contact 1* Name Telephone Emergency contact 2* Name Telephone Do you have sore joints that could worsen by undertaking this activity?* Yes No Have you had or do you have epilepsy or are you concerned in any way that you may have it?* Yes No Do you carry an EpiPen?* Yes No Are you pregnant?* Yes No Do you have any cold or flu-like symptoms?* Yes No Do you suffer from vertigo/are you afraid of heights or rocky scrambles?* Yes No Have you suffered from circulatory issues such as deep vein thrombosis?* Yes No Do you have any health issue we need to know about prior to you taking part?* Yes No Please list any medical/health issue that we need to know about here: Have you been diagnosed by a doctor or health professional with any of the five following medical conditions? Heart disease High blood pressure Emphysema/bronchitis Diabetes Asthma Consent* By taking part in the event you acknowledge you have read and understood the above statement and hereby agree, acknowledge and understand that Kuta Outdoors takes no responsibility and has no responsibility or liability whatsoever for any death, personal injuries, accidents or loss or damage to property or belongings that occur to me before, during or after one of its events (save for death or personal injury caused as result of Kuta Outdoors negligence and other legal responsibility). You further agree that Kuta Outdoors is not liable for any consequential or indirect loss resulting from the cancellation at any time of the event or from any alteration to the event from that specified in the itinerary website or any other form of advertising.