MCF One Event Licence Form

Please answer all of the following 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 this section. This should include the date you first developed the condition, details of any tests, investigations and of 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.

First Name:*

Surname:*

Town:*

Postcode:*

Email:*

Have you ever suffered from or are you currently suffering from any of the following illnesses or conditions:

1) Epilepsy, fits, blackouts or any condition which may cause loss of consciousness?
YesNo

2) Any condition that might cause dizziness, vertigo or loss of balance?
YesNo

3) Have you been unconscious because of a head injury or suffered from concussion?
YesNo

4) Any brain disorder such as a stroke, MS or Motor Neurone disease?
YesNo

5) Any loss of strength, feeling, control or movement of any of your limbs, head or neck?
YesNo

6) Amputation of any part of your limbs with or without an artificial replacement?
YesNo

7) Any condition or operation involving your heart or main blood vessels or any high blood pressure?
YesNo

8) Any kind of tumour or cancer?
YesNo

9) Diabetes? If 'Yes' please state whether treated by diet, tablets or insulin?
YesNo

10) Any psychiatric or emotional illness or any alcohol/drug/substance misuse?
YesNo

11) Any condition affecting your vision or eyes, including colour blindness?
YesNo

12) Are you taking any medication?
(Include all tablets, medicines etc. whether prescribed or bought over the counter.)
YesNo

Info:

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