Geography Student Health and Safety Form, Primarily for Field Trips

It is very important that we hold current, up to date details about your health and emergency contact and any medical conditions you may have so that we can ensure you are as safe as possible on the field trips you will attend. This allows us to; make alterations so the trip to meet your needs, assist you and the Emergency Services if necessary, allow your nominated emergency contact to be quickly informed if needed, allow field trip leaders to contact you on a field trip.

We will also use the information you provide for travel insurance purposes, so please do ensure that this information is as accurate as possible. If you feel that you need to discuss this with someone prior to the trip, please talk to your field trip leader, or email geographyhelp@exeter.ac.uk to discuss it.

NB: Please be aware that the information you provide us will be shared, in confidence, with the education team, the team leading your field course as well as course providers such as hotels/caterers/activity providers. If you DO NOT wish your information to be shared you must notify us in writing at geographyhelp@exeter.ac.uk

Current Information

If any of your details change, it is your responsibility to resubmit the form with your current information. Every year at registration, we will ask you all to recomplete the form, as we understand many of your details will change year to year.

Photography Permission

We will also ask for you permission to use photos of you taken both on field trips and on campus in promotional material.

Code of conduct

Please read the Geography Undergraduate Health and Safety Code for Off Site Activities

By submitting this form you are agreeing to this code of conduct.

Your details
Student Number *
First name *
Surname *
Gender *
If other, please specify
Programme of study *
Current year of study *
If you stated other please provide details
Date of Birth *	/ /
University term time address *
Home address *
University email address *
Personal email address *
Telephone - Mobile *
Telephone - Land line

Next of Kin Information (person to contact in case of emergency)
Name/s *
Address *
Home phone number
Mobile phone number *

Doctor’s Information
Doctor’s name *
NHS number
Address *
Telephone number *

General health & safety Information
Are you in good health? *
Please give details *
Can you swim?	Yes No
If you stated other, please provide details
Do you have specific dietary requirements? *
If yes, please give details
Is there anything you can think of which may impact/restrict the activities and objectives of off-site activities? *
If yes, please give details
Do you have any allergies? *
If yes, please give details
Do you carry personal medication? *
If yes, please givedetails
Have you checked your vaccination status as appropriate? *

Medical conditions
Ambulatory impairment *
Anaemia *
Angina *
Arm or leg/foot injury *
Arthritis or joint problems *
Asthma *
Back/neck pain/condition *
Low blood pressure *
High blood pressure *
Congenital Heart Disease *
Crohn’s disease *
Diabetes *
Epilepsy *
Haemophilia *
Hay fever *
Hearing impairment *
Heart attack *
Heart murmurs *
Hernia *
Mental Health condition *
If yes, please give details
Reynaud’s disease *
Sickle cell anaemia *
Skin conditions *
Ulcerative colitis *
Visually impaired *
If yes to any of the above, please give details
Recent operations *	Yes No
If yes, please give details *
Other
I confirm that I have disclosed every heath concern/issue I have or have had. * ?	If there is anything you have not yet disclosed, please enter it into the 'other' box above.

Photography and Film Footage
I give permission to the University of Exeter for photograph/s and/or footage of me to be used in promotional material for which it may be suitable. The use extends to all publicity for the University, which may include reproduction for printed publications, exhibition boards, digital reproduction for use on the Internet and other media as appropriate. The information will be used in accordance with relevant data protection legislation. Should you change your mind and decide at a later date you wish to opt out please email geographyhelp@exeter.ac.uk *
Street code

Photography and Film Footage

I give permission to the University of Exeter for photograph/s and/or footage of me to be used in promotional material for which it may be suitable. The use extends to all publicity for the University, which may include reproduction for printed publications, exhibition boards, digital reproduction for use on the Internet and other media as appropriate. The information will be used in accordance with relevant data protection legislation. Should you change your mind and decide at a later date you wish to opt out please email geographyhelp@exeter.ac.uk *

Street code