Delegate Information:

First Name:

Surname:

Date of Birth:

School:

Email address:

Confirm email address:

T-shirt size:

Gender:

Position:

If you are of another position not specified above, please state here:

Dietry requirements:

If you are of other dietry requirements not specified above,
please state here:

Contact Numbers:

Name of parent/guardian:

Mr/Ms/Mrs:

Home number:

Work number:

Cellphone number:

Email Address:

General Health:

Do you have any present medical problems?

Are you taking any medication?

Have you had tetanus immunuzation within the last 10 years?

Are you allergic to anything? If so, please state:

Do you suffer from asthma?

If so, has the condition been stable for the past year?

Does your health prevent you from participating
in any physical activities?

If so, please state the activities:

Medical Information:

Detail any medication condition, including allergies:

State any medication or type of pills being taken at present:

Delegate’s Medical Aid Details:

Name of medical aid:

Medical Aid Number:

Main Member’s Name: