Participant Information Form

Event MedCamp Date 4th - 6th of March

The UQMS will do our utmost to ensure your safety at any of our events. In the unlikely case where
something does happen we will use this information to ensure that you receive adequate and timely
medical care. These documents will be shredded post-event to ensure your privacy.

Personal Details Membership No. (Keyring)

Surname Given Name Preferred Name

Home Address Mobile No.

Surburb State Postcode

Date of Birth Age at Activity Gender M F X

Medicare No. Position on Card Exp.

OSHC No. Exp.

Private Health Insurer Ins No. Exp.

Emergency Contacts
Name Tel. No.

Alt. Contact
Name Tel. No.

Medicial Details Any chronic or acute conditions should be disclosed

Physical or Other Disabilities Yes No Specifiy
Asthma Yes No Medication / Explaination
Diabetes Yes No
Epilepsy Yes No
Dizzy Spells or Blackouts Yes No
Sleep walking Yes No
Migrane Headache Yes No
Allergies Yes No Specifiy

Do you have any mediciations on this activity ?or Name

Do you use any street drugs? Dosage
Yes No Administration
Date of Last Tetanus Injection
Details

This information is confidential, and will only be used to assist in the management of an emergency situation
 Participant Information Form
Event Date

PrivacyPrivacy
and Liability
Notice Notice

UQMS respects your privacy. We collect personal information in order to process applications and adminster events and
services that we provide. This includes the use of information to communicate with members and leaders, to conduct
research and improve UQMS’ delivery of services. Your personal information may be retained to send you information
about UQMS’ activities, products and services, unless you let us know that you do not wish to be contacted for these
purposes or would prefer to recieve communications through a different channel.

We may also collect sensitive information, such as health information, to protect and assist in the management
of the health and safety of members and conveners, or process claims under insurance. This information will be kept
private and confidential so far as is practical and destroyed after the conclusion of the event it is provided for. You do not
have to provide this information, but it may affect our ability to care for you in the event of an emergency or to provide
activities for you to participate in.

For the purposes described above, UQMS may disclose your personal information to other members, helpers and leaders
our respective agents and service providers (e.g. First Aid Services) and as may be required or authorized by law, or where
you have otherwise consented. Where practicable, we will always attempt to obtain your consent prior.

Please note that photographs of members, leaders and other participants may be published in UQMS publications, on
our website or through social media channels. While we will take steps to ensure that no embarrassing photos are
published, please contact us beforehand if you have concerns about such publication, or you wish to have an image
removed.

Individuals have rights to access their personal information held by UQMS and ensure its accuracy. If you would like to
request access, or to let us know you do not wish your photograph or name published and to let us know your contact
prefrences, please contact: UQMS Secratary, UQMS Office, Level 3, UQ Health Sciences, Royal Brisbane and Women’s
Hospital, Herston, Qld or by email at secretary@uqms.org

It is your responsibility to ensure UQMS is immediately notified in writing of any potential long term effects of an
injury or illness resulting from a UQMS activity you have participated in.

Some activities offered by UQMS have an inherrant amount of risk involved. UQMS will do everything practicable to
manage this risk, but ultimately you are responsible for an personal injury or loss incurred as a result of a UQMS activity.

I herby Authorise the person in charge of the above activity, in circumstances where it is not possible or
impracticable to communicate with me, to seek such Surgical, Medical or Dental treatment as a qualified
Surgeon, Medical or Dental practicitioner may consider to be necessary, (including the transfusion of blood)
and I hereby Consentto such treatment and agree to cover its reasonable cost.
I have read and understood the Notice and agree to absolve UQMS of responsiblity for loss, damage or injury.

Signature Date

If you do not understand any of the information provided to you, or if you have any concerns, do not sign, and instead
speak to a UQMS representative who will seek to explain the information to you.