Medical Declaration - Professional Courses Only

Acceptance
This medical declaration must be completed by you, to the best of your ability. It will then be reviewed by an Outward Bound Medical Screener/Nurse for final acceptance and confirmation of enrolment.

Full disclosure of medical history is necessary to ensure the participant’s and others’ safety.

Medical conditions may not necessarily exclude a participant, unless indicated, as long as the condition can be appropriately managed.

Medical declaration validity
This declaration is valid for 90 days from the date it is completed and must be valid until the course start date.

Please note: you may be required to have a medical assessment completed by your doctor if the Outward Bound Medical Screener/Nurse requires further information.

For further information please contact Outward Bound on 0800 688 927.

Fields marked with * are required.

Personal Details

Medical details

(anxiety, depression, bi-polar, schizophrenia, eating disorder, alcohol/drug treatment or counselling, suicidal thoughts/attempts, self-harming behaviours)

Must be seizure free for past 5 years (12 months for some adapted courses)

Control of HbA1c (53-64 mmol is required)

If yes, participant cannot attend

Vaccination is recommended by public health service due to the 2019 Measles outbreak and the risks associated with bringing people from all over NZ to Outward Bound.

If you answered 'yes' to any of the above questions, please provide details in the space below - including medication and dates commenced. Please also upload any specialist letters.

Upload any specialist letters here.

Fitness

Water confidence

Smoking & Vaping

DECLARATION

I declare that the information given in this form is true and complete to the best of my knowledge. I understand that I will not be entitled to a refund if:

a) I have not disclosed all previous medical conditions or injuries, or

b) My medical condition changes or I receive an injury after signing this form and do not disclose this to Outward Bound before the course, and these conditions or injuries limit or exclude me from the course.

The safety and wellbeing of participants on an Outward Bound course is the first concern of Outward Bound. However, I understand that all participants take part at their own risk and must accept personal liability for any injury.

I authorise Outward Bound to contact me to obtain further information that may be required.

I acknowledge that, in accordance with the provisions of the Privacy Act 2020, the following information has been brought to my attention:

a) This form collects personal information about me.

b) The information is collected to evaluate my suitability to attend an Outward Bound course.

c) The intended recipients of this information are those staff directly involved with my attendance. Outward Bound staff may share relevant information with other health professionals who may be required to be involved in my health care.

d) The Health Information Privacy Code 1994 under Rules 6 and 7, and the Privacy Act 2020 entitles me to have access to, and request a correction of, the information. Where correction is not made, a statement of request for correction will be attached to my records.

e) The information is being collected and held by Outward Bound.