Ride for Life 2022 - participant medical form - 1 Day Challenge About youFirst name(s)* Last name* Email* Phone number you will have on you on the day*Do you have any dietary requirements? If yes please give details:* Medical detailsHave you ever suffered from the following: • Heart problems • High/Low blood pressure • Asthma, Bronchitis or severe shortness of breath • Tendon, ligament or cartilage damage • Vertigo • Infectious Disease • Eczema or skin problems • Diabetes • Epilepsy • Head Injuries • Cancer • Fractures or broken bones • Back problems • Migraine or severe headaches If you have suffered from any of the conditions above please give further details including the last time an incident occurred:*Do you have any allergies? If yes please give details:*Are you currently taking any medication? If yes, please provide the type, frequency and what it is being used to treat:*Have you been hospitalised in the past two years? If yes please give details below:*Do you have any problems with sight, hearing or other senses? If yes please give details below:*Are there any other medical issues you think we should be aware of? If yes please give details below:*Tick to confirm* I confirm that all details provided on this form are true to the best of my knowledge. Tick to confirm* I confirm my general health and fitness is good and I agree to take responsibility for myself throughout the event. YOUR PRIVACY Your information is held securely with all reasonable precautions used to protect it. If you are an EACH donor or supporter, your data may also be used for profiling to help us provide the best service possible. We will only allow your information to be used by suppliers working on our behalf and will only share it elsewhere if required to do so by law. This information will be shared with Chapeau Events, the event logistics company running Ride for Life on behalf of EACH. For full details, please see our privacy policy. or email supportercare@each.org.uk . CAPTCHA
