Group snorkeller form

1
Your name* This field is required.
First Name
Last Name
2
What group are you coming to LIRS with?* This field is required.E.g., your school or university
3
When will your group arrive at LIRS?* This field is required.
Date
Day
Month
Year
4
Your email address* This field is required.
example@example.com
5
Your phone number* This field is required.Australia's country code is 61. Use 04 as area code for Australian mobiles.
Country Code
Area Code
Phone Number
6
Your home address* This field is required.
7
Your nationality* This field is required.
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
8
Your emergency contact* This field is required.Must be a parent or legal guardian if the snorkeller is not yet 18 years old. Others should list a person who is not at Lizard Island with them.
Name of emergency conact
Please Select
Please Select
Spouse/partner
Parent
Daughter/son
Sibling
Other family member
Friend
Emergency contact's relationship to you
9
Emergency contact's phone number* This field is required.Australia's country code is +61. Use 04 as area code for Australian mobiles.
Country Code
Area Code
Phone Number
10
Emergency contact's email or home address* This field is required.We need a second way of getting in touch if phone doesn't work.
11
Your date of birth* This field is required.Medical services need your date of birth if we have to contact them on your behalf.
Date
Day
Month
Year
12
Do you have a medical condition that can be made worse by physical exertion (e.g. asthma, heart disease, some lung complaints) or brought on by cold water or salt water mist (e.g. asthma)?* This field is required.
Yes
Maybe
No
13
Do you have a medical condition that can result in loss of consciousness (e.g. some forms of epilepsy, some diabetic conditions).* This field is required.
Yes
Maybe
No
14
Please identify your medical condition(s) and provide information about them, especially as they relate to snorkelling and boating.* This field is required.
15
Are you taking any prescribed medications?* This field is required.No need to tell us if you take an oral contraceptive.
YesNo
16
List your prescribed medications* This field is required.
17
What is your level of physical fitness for your age?* This field is required.1 is poor, 3 is average, 5 is excellent
1
2
3
4
5
18
Do you smoke?* This field is required.
YesNo
19
Are you overweight?* This field is required.If your preferred answer is "just a bit", please select No.
YesNo
20
Can you swim 100 metres in a pool?* This field is required.
Easily
With some difficulty
No
21
Can you float on your back for at least 5 minutes?* This field is required.
Yes
No, or don't know
22
Can you tread water for at least five minutes?* This field is required.
Yes
No, or don't know
23
Have you ever snorkelled before?* This field is required.
Yes
No
24
Are you physically fit enough for this trip?* This field is required.It requires a reasonable level of flexibility, strength, and cardiovascular fitness. You must be able to get in and out of small boats and light aircraft, snorkel for an hour, and walk on soft sand for at least a kilometre.
YesNo
25
I am over 18, or I will be 18 by the start of my trip to LIRS* This field is required.
YesNo
26
Parent statement* This field is required.For snorkellers who are under 18, the parent or legal guardian listed as the emergency contact in this form must agree to the following statements: 1. I am the parent or legal guardian of this snorkeller who is not yet 18 years old and I am the person identified as the snorkeller's emergency contact in this form. 2. I give permission for the snorkeller to take part in snorkelling and boating activities at LIRS. 3. I understand that those activities will be supervised by people who are authorised to do so by the organiser of the trip and they will follow the relevant LIRS regulations. 4. I confirm that the information provided in this form is complete and true to the best of my knowledge.
I agree
27
Snorkeller's statement* This field is required.You must agree to this statement to register as a snorkeller at LIRS: I confirm that the information provided in this form is true and complete to the best of my knowledge and I agree to follow the instructions of my group's snorkelling coordinator.
I agree
Should be Empty: