BOSIET Course FormΔ Subscribe Course RegistrationMedical ScreeningBIOSET Registration SECTION 1 – COURSE DETAILSCourse NameCourse Start DateCourse End DateSECTION 2 – PERSONAL DETAILSFirst NameMiddle NameLast NameDate of BirthCompany's NameJob TitleSECTION 3 – SELF AND EMERGENCY CONTACT DETAILSSECTION 3 – SELF AND EMERGENCY CONTACT DETAILSAddressPhone NumberEmail AddressNext of Kin NameNext of Kin Contact NoPreviousNextSECTION 4 - PERSONAL HEALTH INFORMATION TO PRIOR TO COMMENCING TRAININGDo you suffer from any of the following? YESNOClaustrophobia (fear of enclosed spaces)Asthma/ BreathlessnessLung-diseaseFits or fainting spellsHypertension (high blood pressure)DiabetesHeart-diseasePhysical disabilitiesFractures/ DislocationMental disabilitiesImpaired Vision ***Impaired HearingAre you under any medication at the present?PreviousNextEmailGender- Select -MaleFemaleCompany/Sponsor NamePLEASE, TICK AS APPLICABLE:Your Age Range- Select -16-2020–2525–3535–4040–4545–5050-5555 & AboveHave you participated in BOSIET Training involving HUET before? Yes NoIf yes, state yearAre you on any or special medication? Yes NoIf yes, please specify Do you have any health condition or other reasons that you consider not appropriate for swimming or immersion in water or getting close to fire within safe range? Yes NoIf yes, please indicateDo you have any other personal or confidential information about your health or concerns about sharing the pool with others at the same time? Yes NoIf yes, please indicateAre you in possession of any weapon? Yes NoIf yes, please indicateHave you ever had surgery? Yes NoHave you ever had any significant injuries or accidents? Yes NoDo you use any assistive devices or mobility aids (e.g glasses, walking-stick)? Yes NoAre you currently experiencing any ongoing medical issues or symptoms? Yes NoAre you pregnant, trying to become pregnant or did you just give birth? Yes No N/AOther? Please, specify: ATTESTATION I attest that the information I have provided are true, accurate, and complete about myself. I fully understand that any falsification, omission, or concealment of personal facts or information may subject me to personal risk or the represented organization that I represent to administrative, civil, or criminal liability. Furthermore, I am aware that by appending my signature below this attestation, I have read and have understood the questions and have provided correct answers to all the questions.NameName of Company/SponsorDateSignature Sign Here Previous Submit
