As a part of the block booking for a Champs Parc practice day it is a requirement for non NORA licence holders to complete the following form ahead of arriving at the venuw for your session
This system has been put in to place following the Coronavirus outbreak, reducing the need for completing forms at an event reducing the risk of transmission of the virus
By submitting the forom you agree to abide by the declaration as set out below:
Please enter your NORA licence number, if you dont have a licence then please complete this
Please tick the box if the answer to any question is YES.
Please answer all the questions truthfully. A false declaration may have serious consequences. If you answer 'Yes' to any of the questions, please give full details in the space provided at the end of the section. This should include the date you first developed the condition, details of any tests, investigations and any treatment you have undergone. Please include the names and addresses of any specialists you have seen and hospitals you have attended Please give full details of any medication you are taking. In completing this application, you consnt to any information concerning an injury at an event being given by the attending medical staff to the Clerk of the Course at the event.
Epilepsy, fits, blackouts or any condition which may cause loss of consciousness?
Any condition that might cause dizziness, vertigo or loss of balance?
Have you ever been unconscious because of a head injury or suffered from concussion?
Any brain disorder such as a stroke, MS or Motor Neurone disease?
Any loss of strength, feeling, control or movement of any of your limbs, head or neck?
Amputation of any part of your limbs with or without an artificial replacement?
Any condition involving your heart or main blood vessels or any high blood pressure?
Diabetes? If 'Yes' please state whether treated by diet, tablets or insulin?
Any psychiatric or emotional illness or any alcohol/drug/substance misuses?
Any kind of tumour or cancer?
Any condition affecting your vision or eyes, including colour blindness?
Are you taking any medication?
Please add any further information on Diabetes, medicines taken (either prescribed or bought over the counter) or any other relevant information in the box below.
Extra medical information
I am 18 or overI am under 18
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