Local Operating Procedure (LOP)
Serco Management
High Ropes Facility
System
LOP 28-01 Appendix 13 – Confidential Medical Information
This form is to be completed by anyone taking part in a High Ropes activity session at RAF Halton’s High Ropes
Facility (HRF). This form will be destroyed after the High Ropes session except after an accident or incident,
when it will be retained.
PERSONAL DETAILS - Please complete the following:
Full Name:
Home
Telephone:
Date of
Birth:
Mobile Telephone:
Gender:
Contact in case of an emergency:
Name:
Contacts
Telephone
Your relationship to
contact:
Contacts Mobile:
MEDICAL DETAILS - Do you currently have, or have you ever had (Please circle YES or NO):
Heart problems of any kind?
YES / NO
High blood pressure?
YES / NO
Recurrent back problems?
YES / NO
Epilepsy, seizures, convulsions or medication to control them?
YES / NO
Asthma, wheezing with breathing or wheezing with exercise?
YES / NO
Diabetes?
YES / NO
Any arm or leg problems?
YES / NO
Do you regularly take prescription or non-prescription medication
(excluding contraception)?
YES / NO
Females only: Are you pregnant?
YES / NO
Have you undergone any form of surgery in the past six months? If so, you require the
written consent of a competent medical practitioner.
YES / NO
Are there any other medical conditions that you think the instructional staff should be
aware of?
YES / NO
PLEASE TURN OVER
Document Title: Confidential Personal & Medical Information
Document No: LOP 28-01 Appendix 13
Issue Date: 1 May 2012
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If you answered ‘YES’ to the last question, please give details here:
If you have answered ‘YES’ to any of the above questions, you should bring this to the attention of your
instructor. It will not necessarily prohibit you from taking part in an activity on the HRF.
Acknowledgement of Risk
There will always be some risk involved in any type of adventurous activity, and indeed the benefits of the
activity would probably be nullified if these risks were completely removed. The type of risk is generally
confined to the same sort of risks that a normal adult involved in normal active recreation may experience.
The level of risk is considered to be low and reasonable. However, YOU must decide if you also consider it
to be reasonable. Our ‘Challenge by Choice’ approach endeavours to ensure that participation in any activity
is always at your own discretion.
DECLARATION
I have read and understood the above statement. The information I have provided about my medical details
is accurate to the best of my knowledge.
Participants Name
Signature
Date
Signature
Date
FOR INSTRUCTORS USE ONLY
Elements to be omitted:
Instructors Name
Document Title: Confidential Personal & Medical Information
Document No: LOP 28-01 Appendix 13
Issue Date: 1 May 2012
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