Form FW4

Confidential Personal Details Form

To be insured, the University Policy requires this form to be completed by all staff and students prior to the commencement of overseas travel.

Activity, including module code if relevant:
Full name:
Programme of Study (Students only) / Student Number / Year:
E-mail: / Mobile number:
Date of Birth:
Address: (if student – Semester address)
Name & Address of next of kin (to be contacted only in an emergency) please state relationship
Telephone numbers of next of kin (home/work/mobile):

Insurance cover is excluded when travelling against medical advice or for the purpose of obtaining treatment or medical advice. YOU MUST DISCLOSE ANY PRE-EXISTING CONDITIONS.

Name of Doctor:
Address:
Your NHS Number:
Do you suffer from any of the following? / Yes / No
Asthma or bronchitis
Heart condition
Fits, fainting or blackouts
Severe headaches
Diabetes
Allergies to any known drugs
Any other allergies e.g. bee stings/material/food
Other illness or disability
Travel sickness
Back, knee or other joint problems
Any break or injury
If the answer to any of the questions above is YES please give details here:
Do you suffer from Deep Vein Thrombosis (DVT)? / Yes / No
Have you received vaccination against Tetanus in the last ten years?* / Yes / No
Are you currently taking any prescription medicine? If Yes, give details below / Yes / No
Are you currently receiving medical or surgical treatment of any kind from either your Doctor or a Hospital? If Yes, give details below / Yes / No
Have you been given specific medical advice to follow in emergencies? If Yes, give details below / Yes / No

Permission for Emergency Treatment

I DO/DO NOT give my permission for the first aider or trip leader to sign for emergency treatment deemed necessary by a Doctor, in the event of my being unconscious and unable to make a decision
Signed: / Date:

*NB adults should receive a routine tetanus every 10 years. If travelling internationally this should be up-to-date. If you receive a wound and it is more than 5 years since your last booster shot, another booster shot is needed.