STRIVE Bhutan

Personal Details

Name

First name Surname

Date of Birth*

Gender*

Male
Female
Other
Prefer not to say

Nationality*

Place of Birth*

Passport Number*

Passport Expiry Date*

Contact Information

Email address*

Enter Email Confirm Email

Primary Phone Number*

Address

Address Line 1 Address Line 2 City or Town County Postcode Country

Company

Medical Information

Could you be pregnant?*

Yes
No

Have you had any previous medical conditions, investigations or treatments in the last two years?*

Yes
No

Please give details:*

Do you have any current medical conditions?*

Yes
No

Please give details:

Do you suffer from, or a carrier of, any blood borne infectious diseases?*

Yes
No

Please give details:

Do you have any allergies?*

Yes
No

Please give details:

Do you consider yourself to have a disability?*

Yes
No

Please give details:

In the event of it being deemed necessary by a medical professional, do you have any objections to any form of medical treatment of invasive intervention, if unable to consent at the time?*

Yes
No

In the event of it being deemed necessary by a medical professional, do you have any objections to blood transfusions, if unable to consent at the time?*

Yes
No

In the event of an incident, do you have any objections to a nominated representative of the event team contacting your next of kin, if unable to consent to at the time?*

Yes
No

Will you be in good physical shape and will you be prepared to cycle/hike for 8 hours a day?*

Yes
No

Please detail any medication you are taking:

Dietary Requirements

None
Vegetarian
Vegan
Coelic
Gluten free
Lactose intolerant
Halal
Other

Please specify:

Next of Kin Information

Next of Kin First Name*

Next of Kin Last Name*

Next of Kin Mobile Contact Number*

Next of Kin Address

Address Line 1 Address Line 2 City or Town County Postcode Country

Relation to you*

Parent
Spouse
Sibling
Friend

Are You Already A Striver?

Have you taken part in a previous STRIVE Event?*

Yes
No

Which event?

STRIVE 2014
STRIVE 2015
STRIVE 2016
STRIVE Morocco
STRIVE 2018
Alpine STRIVE

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For example, Noah’s would be “Strive co-founder, Big Change community director, husband and father

Terms and Conditions

What's App Consent

I am happy to added to a Whats’App group for all challenge participants

Terms and conditions consent*

I agree

By ticking this box I agree to the Terms and Conditions and I give my permission to Big Change and Strive Bhutan 2020 to process the data I have provided in this form with relation to Strive Bhutan 2020.

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Personal Details

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Next of Kin Information

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