Skip to content

ExpedNZ
Whenua Iti Foundation
Safety First
Trades Academy
Booking Enquiry
Nature Connection Programmes

Programmes
Our Purpose
Who We Are
Resources
Contact

Search for:

Programmes
Our Purpose
Who We Are
Resources
Contact

Search for:

Medical Form

Please complete this form to provide necessary information for our team to best support you to attend our programmes.

Contact us if you have any questions, or need more information to complete the form.

1Personal Details

2Sign Off

Medical Form
If the participant is under the age of 16, please have a parent or guardian fill this form in on their behalf.
Personal Details
Name*
First Name Last Name
Contact Email*
A copy of this form will be sent to the email provided.
Date of Birth*
DD slash MM slash YYYY
Which programme are you attending?
What is the name of the programme (if known)?
Medical Declaration
Whenua Iti Outdoors(WIO)/ExpedNZ aims to accommodate the needs of every individual on our programmes. At times our programmes operate in remote areas with limited access to medical resources and facilities. We ask that you provide as much detail as possible of ANY pre-existing medical conditions or behavioural needs.

The programmes on offer are designed to promote personal growth outcomes such as resilience and confidence. They are not designed as therapeutic intervention, if a higher level of support is required please contact us for suitable alternatives.

If medical or behavioural information is not declared, we reserve the right to not accept applicants on arrival. Whilst on programme if applicants behaviour or medical issues raise either safety concerns or negatively impact the group, they may be asked to depart the programme early.
Should there be any changes to information supplied prior to programme start, it is your responsibility to inform WIO/ExpedNZ.

Thank you kindly for supplying information that allows us to best support applicants needs.
I have read the above statement*
- Yes
Do you have any of the following medical conditions?*
- Diabetes
- Asthma
- Epilepsy
- None of these
Diabetes Information
Please complete the following questions to help us best support you on our programme.
Have you been admitted to hospital as a result of diabetes?*
- Yes
- No
Please provide details of your admission(s) and when this occurred*
Do you carry insulin?*
- Yes
- No
Do you require assistance with administering your medication?*
- Yes
- No
How do you manage your condition?*
Please give details of testing, medication & food requirements as applicable.
Asthma Information
Please complete the following questions to help us best support you on our programme.
Have you been admitted to hospital as a result of asthma?*
- Yes
- No
Please provide details of your admission(s) and when this occurred*
Do you carry an inhaler or other forms of medication?*
- Yes
- No
Do you require assistance with administering your medication?*
- Yes
- No
How do you manage your condition?*
Please include how often you need to take an inhaler, what causes your asthma to worsen (if known) and if it is likely to affect your ability to take part in any activities.
Epilepsy Information
Please complete the following questions to help us best support you on our programme.
Have you been admitted to hospital as a result of epilepsy?*
- Yes
- No
Please provide details of your admission(s) and when this occurred*
What form of epilepsy do you have?*
When was your last seizure?*
How often do seizures occur?*
Do you require medication for epilepsy?*
- Yes
- No
Do you require assistance with administering your medication?*
- Yes
- No
How do you manage your condition?*
Please include how often you need to take medication and the doseage, if there are any likely triggers and which activities it affects you participating in.
Other Medical Information
Do you have any other medical condition we may need to know about?*
- Yes
- No
Please provide further details*
Please provide details including frequency, severity, your management plan and any concerns you have for attending the programme.
Do you have any allergies?*
E.g. bee or wasp stings, penicillin, certain foods.
- Yes
- No
What are your allergies to?*
Have you had an anaphylactic reaction as a result any of these allergies?*
- Yes
- No
Please provide details of your reaction(s), including your symptoms, and when this occurred.*
Do you carry an epipen?*
- Yes
- No
What is the response plan if you are exposed to the allergen?*
Do you have any mental health conditions/concerns?*
- Yes
- No
What is the condition/concern that affects you?*
Please provide details of how you are affected, how often and any triggers you are aware of.
Do you take any medication or other treatment?*
- Yes
- No
Please provide details*
If medication, please provide the name, doseage and frequency given. If treatment, please provide further information.
Is there any other information you can provide our instructors to best support you on our programme?*
Do you take any (other) medication?*
- Yes
- No
Medication Details*
Please state which medications you are taking, the doseage and frequency.
Do you require assistance with taking this medication?
- Yes
- No
Do you have any current or previous injuries or illnesses which may affect your participation?*
E.g. dislocations, back injuries, sprains, or broken bones.
- Yes
- No
Injury or Illness Details*
Do you have any special dietary requirements?*
E.g. vegetarian, vegan, gluten free, sugar free (If you have a food allergy please provide details in the allergy question above)
- Yes
- No
Dietary Requirements Details*
On a scale of 1 to 5 how would you rate your overall fitness?*
1 = Very unfit / 5 = Super fit
- 1
- 2
- 3
- 4
- 5
On a scale of 1 to 5 how would you rate your swimming ability?*
1 = Non-swimmer / 5 = Very capable & confident
- 1
- 2
- 3
- 4
- 5
Please give details of your swimming capabilities.
Is there anything else we should know about you? For example do you have any individual learning needs that we need to be aware of? E.g dyspraxia, Asperger's, autism, dyslexia, anxiety, fear of heights, claustrophobia*
- Yes
- No
Please provide further details*
This information will assist our instructor team to support your learning needs during the programme
Risk Management Consent
When taking part in any adventure activity, risks are encountered that could result in emotional and physical injury up to and including fatality. WIO/ExpedNZ manages these risks with the use of highly trained staff who make decisions about acceptable risks, while enabling participants to build their skills, knowledge, experience, confidence and judgement. WIO/ExpedNZ will take all reasonable steps to manage risks to an acceptable level and to set appropriate safety standards. At times WIO/ExpedNZ staff will make decisions on behalf of the group about the acceptability of certain risks. Participants must follow the instructions of staff in regard to safety and risk management.

I understand that there are risks associated with activities in the outdoors. I am aware that WIO/ExpedNZ will take all reasonable steps to manage these risks to an acceptable level and to set appropriate safety standards. Where a participant does not comply with the instructions of any WIO/ExpedNZ staff member in regard to safety or risk management, I acknowledge that WIO/ExpedNZ may not be held responsible for any outcome.
I understand the Risk Management Consent*
I have read, and give my consent to, the risk management policy as outlined above.
- Yes
Behaviour Consent
During the course WIO/ExpedNZ reserves the right to depart a student early, without refund, if undisclosed behavioural issues are deemed to cause safety concerns or unfairly impact the group.
I understand the Behaviour Consent*
- Yes
Media Consent
During the course WIO/ExpedNZ may take photographs or video. Some of this media (generally group shots) may appear in our publicity material including, but not limited to, Course publications, Facebook, Instagram, newsletter and website material. By signing this declaration, you give WIO/ExpedNZ permission to use photographs or video containing the images of you/your child for this purpose. Individual students will not be named.
I give my consent for media use as outlined above*
I agree and give my consent to the media policy as outlined above.
- Yes
- No

Sign Off
Declaration of Information*
All information on this form is accurate to the best of my knowledge. I am aware that should medical or other information change that I need to inform WIO/ExpedNZ.
- Yes
Date*
DD slash MM slash YYYY
Thank you for completing your application
Please submit your form below.
Name
This field is for validation purposes and should be left unchanged.

Want to find out more about a programme or have a question for us? Talk to one of our friendly team - we're happy to help.

Get In Touch

03 526 7842

[email protected]

375 Main Rd Lower Moutere
RD2
Upper Moutere 7175

Connect with us on Social Media:

Programmes

Primary Programmes
Secondary Programmes
Holiday Programmes
International Students
Duke of Edinburgh's Award
Community & Wellbeing

Info & Resources

Latest News & Events
Our Policies
Downloads

About

Whenua Iti Foundation
Our Kaupapa
Safety First
Our Partners
Our Location

Subscribe to our newsletter

Get our latest news & programme information direct to your inbox.

Name

Please enter your name.

Email Address

Please enter a valid email address.

Thanks for subscribing! You can unsubscribe at any time from the link at the bottom of our newsletters.

Something went wrong. Please check your entries and try again.

© 2024 Whenua Iti Outdoors. All Rights Reserved. Built with ❤️ by Avoca Web Design