Participant Information M14 Outdoor Excursion

First Name

Last name

Addres

City

ZIP / Postal code

Country

Nationality0 / 1

GenderMaleFemaleOther

Date of birth

Name of school & semester

Sopken language

Body heightIn centimeters (needed for bike rental)

Email

Please describe your level of experience in mountainbiking

Health Insurance

Social security number

Vaccinations (please fill out according to the information in your vaccination pass. If possible, please add a photocopy of your vaccination pass)

No file chosen

Diphteria

Date of vaccination

Tetanus

Date of vaccination

Polio

Date of vaccination

Meningitis

Date of vaccination

Please describe any possible health/physical/behavioural limitations and, if possible, complete the information with a date. (Includes illnesses, accidents, mental health issues, seizures, hospitalisation, operations, rehabilitation, hyperactivity, allergies, diabetes, asthma). *

Are you currently undergoing any sort of medical treatment? If yes, please indicate.

Do you have any nutritional allergies? If yes, please indicate.

Are you vegetarian and / or would you like to be provided with vegetarian food during the program?YesNon

Please provide contact details of one or more emergency contacts. (Name, Adress during the program, Mobile phone number, Work/Home phone number)

We inform you that the project organiser reserves the right to exclude a participant for disciplinary reasons, health reasons or any other reason, which could have an impact on the well-being and/or safety of other participantsI understand

There may be pictures taken of the participants during the programme which can be published by NBE for publicity reasonsI understand

I hereby certify that for the duration of this programme (17.05.21-20.05.21) I am not required to undergo a mandatory phase of quarantine and self-isolationI understand

If you experience any sort of flu-like symptoms or other indicators prior to or during the program that could be caused by Covid-19 (fever, loss of smell / taste, coughing, joint pain, chills), please understand that we cannot let you take part in any activities in order to protect the health and well-being of yourself and the other participants.I understand