Adult Medical Form

Please complete each question.

Step 1 of 3

Traveller Information
First Name*
Surname*
Date of Birth*
Mobile Phone*
Email*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Medicare Number
Medicare Position on Card
Medicare Expiry
Private Health Fund Name
Private Health Fund Number
Swimming Ability*
- Non-Swimmer
- Up to 25m
- Up to 50m
- Over 50m

Indemnity
Please visit https://www.redearth.edu.au/privacy-policy/ to view our Privacy Policy.
*
- 1. I consent to undertaking and participating in the Activity. I confirm that I am in sufficiently good health to undertake the Activity and that I have or will inform Red Earth of any relevant allergies or special needs prior to departure.
*
- 2. In the case of an emergency, I authorise Red Earth (REO) and/or the Organisation I am travelling with, where it is impracticable to communicate with me, to arrange for me to receive medical or surgical treatment as may be deemed necessary. I also undertake to promptly pay or reimburse costs which may be incurred for medical attention, ambulance transport and medication while I am undertaking the Activity or should I need to be transported home on any account.
*
- 3. I understand that although REO and the Organisation/Group I am travelling with, attempt to minimise any risk of personal injury within practical boundaries, accidents do happen and all physical activities carry the risk of personal injury. I acknowledge that there is an inherent risk of personal injury in physical activities that will be undertaken by myself in the course of the Activity and I accept that risk and release, indemnify and hold REO and the Group/Organisation harmless in relation to that risk.
*
- 4. I understand that while REO and/or Group/Organisation takes all reasonable steps to ensure that personal property is carried safely while being transported during the Activity, REO and the Group/Organisation accept no responsibility for loss of damage to my property taken on the tour including without limitation, any electronic devices taken on tour. I release, indemnify and hold REO and the Group/Organisation harmless in respect of any loss or damage to my property during the Activity.
*
- 5. I consent to allowing REO and/or the Group/Organisation to use any photographs, sound and film recordings taken of me while participating in the Activity, including any comments or quotes, for the promotion of REO’s programs to the media and the general public.
*
- I understand and consent to Red Earth using this information to contact me about the program.

Adult Medical Form

Adult Medical Form

Step 1 of 3

Traveller Information

Merchandise

Emergency Contact Information

Medical & Dietary Information

Indemnity

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