Cycling Tour Health Declaration Form
Personal Information
Full Name
Date of Birth
Phone Number
Email Address
Emergency Contact
Name
Phone Number
Relationship
Health Information
Do you have any medical conditions we should be aware of?
Are you currently taking any medication?
Do you have any allergies?
In the past 14 days, have you experienced any of the following? (Check all that apply)
Fever
Cough
Shortness of breath
Sore throat
None of the above
Have you been diagnosed or exposed to any communicable diseases recently?
Yes
No
Other relevant health information
Declaration
I declare that the information provided above is accurate to the best of my knowledge.