@ Phillip Island Adventure Resort, 1775 Phillip Island Rd,
Cowes, Victoria 3922. Phone: 03 5952 2417

You will need to complete a Medical and Consent Form for all attendees (each participant adults & children)

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* 1. Contact details

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* 2.  Allergies and special diet                                  TSAA endeavours to organise through caterer safe, healthy meals to all clients, including those with special dietary needs.
Those at risk from food related anaphylaxis require the highest level of care. It is important that we receive information
regarding food related allergies even if the participant is
attending a self-catered program.
If the participant has a special dietary need, please provide information below. If not applicable, select n/a.
1. Food related anaphylaxis diagnosed by a doctor. Please indicate prescription and the item/s the participant CANNOT eat

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* 3. Food related allergy or intolerance. Please indicate the item/s the participant CANNOT eat - allergy or intolerance
If not applicable, select n/a.

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* 4. Food related allergies/aversion/religious beliefs/
lifestyle choice. Please indicate the participant’s special diet. 
If not applicable, select n/a.

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* 5. Non-food related allergy. Please indicate the participant’s non-food related allergy.
If not applicable, select n/a.

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* 6. Does the participant have any of the following
(If not applicable, select n/a.)

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* 7. Medicare Number

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