ZO4041 Tropical Ecology Field Course 2012
Your full name (as per your passport)
Your student number:
Your normal address
Your mobile phone number
Will this have ‘roaming’ for use in Kenya?
Can you pick up voicemail abroad?
Name of person who should be contacted in any emergency and their relationship to
you
Address of contact person
Land line of contact person (day)
Land line of contact person (evening/night)
Mobile phone number of contact person
Details of any pre-existing medical conditions that you have (please tick if ‘yes’):
Asthma or bronchitis
Fits, fainting or blackout
Diabetes
Allergies to known drugs
Injury or fracture
Heart condition
Severe headaches
Back, knee or joint problems
Any other allergies (e.g. food)
Other illness or disability
(physical or mental)
If you ticked any of these, please provide details including treatment or medication (and
dosage) you are receiving and the extent to which the condition limits your actions.
Have you received a vaccination against tetanus in the last five years?
Yes/No
Are you receiving any medical or surgical treatment of any kind (not covered above) from
your doctors or a hospital
Yes/No
Have you been given specific medical advice to follow in emergencies?
Yes/No
If you have answered YES to any of the last three questions, please provide details.
Do you have any specific dietary requirements (e.g. vegetarian)?
Yes/No
Details if yes
Please state your Travel Insurance Number (which must include provision for medical
treatment and emergency air evacuation), Insurance Company and their contact details
Name and address of your GP
Do you have a current, valid qualification in first-aid training?
If yes, when does it expire?
Have you previously visited the tropics?
Yes/No
If so, where?
I AGREE THAT DR. IAN DONOHUE, DR. NATALIE COOPER OR DR.
ANDREW JACKSON MAY TAKE DECISIONS ABOUT MY HEALTH
TREATMENT IN THE EVENT OF ANY EMERGENCY, AND CONTACT THE
PERSON I HAVE NAMED ABOVE.
I ENSURE THAT I HAVE CONSULTED WITH A MEDICAL PRACTITIONER
AND HAVE TAKEN ALL NECESSARY MEDICAL PRECAUTIONS TO BE
ABLE TO TAKE A FULL PART IN THIS FIELD COURSE.
Signature…………………………………………….. Date………………..