Challenge Registration Form - Minhaj Welfare Foundation

Name

First

Last

Address

Address Line 1

City

State / Province / Region

Postal Code

Country

Phone

Gender

Date of Birth

Email

T-shirt size

Medical Information

Please specify any conditions previous or present which may impact your climb or you feel we should know about. (If none, please state none.)

Medications taken (If none, please state none.)

Are you allergic to any forms of medication ? If yes, please specify

Do you suffer from any other allergies which may affect your health during the challenge? If yes, please specify

Have you attended hospital in the last 6 months for an illness or injury? If yes, please specify.

How did you find out about our organization?

Emergency Contact Details

Next of kin and someone who is not attending the event

Full Name

Contact Number

Relationship to you

Challenges include activities with a danger of serious injury or fatality. Participants of any activity should be aware of and accept these risks and be responsible for their own safety and involvement. Minhaj Welfare Foundation cannot accept responsibility for any injuries which may occur on any of our activities. We advise all participants to take out Insurance before any activity. I am submitting this form to confirm all the above information is correct and I am happy to pass this information to Minhaj Welfare Foundation to retain.

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Emergency Contact Details

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