MIF Volunteer Medical & Consent Form MIF26 Volunteer Medical and Consent Form NAME(Required) First Last DATE OF BIRTH(Required) DD slash MM slash YYYY DETAILS OF ANY DIETARY REQUIREMENTS including vegetarian and allergies, OR STATE 'NONE':(Required)1st EMERGENCY CONTACT Name(Required)EC1 RELATIONSHIP(Required)EC1 HOME PHONE(Required)EC1 MOBILE PHONE(Required)2nd EMERGENCY CONTACT Name(Required)EC2 RELATIONSHIP(Required)EC2 HOME PHONE(Required)EC2 MOBILE PHONE(Required)PLEASE GIVE THE NAME, ADDRESS AND TELEPHONE NUMBER OF YOUR DOCTOR:(Required)DETAILS OF ANY DISABILITY OR MEDICAL CONDITION, OR STATE 'NONE':(Required)Please note: The organisers of the Mersea Island Festival reserve the right to ask participants to return home if they are likely to be at risk to others due to their health needs.ARE YOU ON ANY MEDICATION?(Required) Yes No IF YES, PLEASE PROVIDE THE NAMES OF THE MEDICATIONDO YOU REQUIRE ASSISTANCE WITH TAKING MEDICATION?(Required) Yes No Not applicable DECLARATION by Volunteer(Required) I hereby certify that the above information is correct to the best of my belief and gives all the relevant details of which I am aware.Consent(Required) I understand the importance of advising the Festival organisers of any medical or special needs which may require particular attention in order to enable my full and safe participation in the Festival.(Required)Consent(Required) If at any point during the Festival I require urgent medical treatment, and provided neither of the emergency contacts can be contacted personally, I agree to authorise members of the staff during the Festival, to approve such medical treatment for myself as is deemed necessary on the advice of a medical practitioner.(Required)Consent(Required) I undertake not to attend the Festival if I have been in contact with infectious diseases within two weeks of the commencement of the visit.(Required)Consent(Required) I understand that the Mersea Island Festival Trust reserves the right to exclude any person before or after commencement of the Festival should important personal details have not been fully declared, or an Attendee’s behaviour be deemed inappropriate and/or incompatible with the health, safety, well-being or enjoyment of other Attendees.(Required)Consent(Required) I understand that during the Festival, photographs and /or video recordings may be taken and used for evaluation or promotional purposes by the Trust or it’s partners. If I do not wish to be photographed or videoed, I will notify the Co-ordinator prior to the Festival.(Required)
Donate today
Donate today