Leicestershire Orienteering Club 
If you prefer to keep details confidential you may put the form into a sealed envelope marked with your name and “Medical Information”.  Hand the form to the coach at the start of the session and ask for it to be returned to you at the end.  The envelope will only be opened in case of medical emergency.
MEDICAL DATA FORM 
(PLEASE COMPLETE IN BLOCK CAPITALS)
Venue and Date: 	
Full Name:…………	D.O.B	
Address:..	
	
Name and contact address of Next of Kin:	Name and contact address of Doctor:
………..			

Telephone……		Telephone….	
Mobile Telephone….	
Any medical disabilities, treatment, medication, allergies or any other relevant information that the coach/group leader should be aware of when planning the session or in case of medical emergency (e.g. uses inhaler, hay fever sufferer etc.).

I acknowledge receipt of, and understand all of the published information regarding the proposed activity / visit as outlined above. 
Signed:		Date: