Lesotho Trip Dietary & Medical Form This field is hidden when viewing the formNext Steps: Install a Payment Add-OnTo accept payments on this form you will need to install one of our payment add-ons. To learn more about your payment add-on options, visit the following page (https://www.gravityforms.com/blog/payment-add-ons). Important: Delete this tip before you publish the form.Name (as appears on passport)(Required) First Last Email(Required) Enter Email Confirm Email Phone number(Required)Date of Birth(Required) MM slash DD slash YYYY Emergency contact – name & relationship to you(Required)Emergency contact – contact details: phone and email(Required)Medical conditions – select any that apply(Required) I do not have any of the medical conditions listed below Heart issues or raised blood pressure Cancer Psychiatric or mental health condition Asthma, bronchitis or shortness of breath Epilepsy / fainting attacks Diabetes Digestive or bowel disorders Allergies Joint or back problems Migraines Fractures, tendon, ligament / cartilage damage Infectious diseases Severe head injury Are you registered disabled Another condition – provide details below Provide relevant details of any conditions outlined above including any medications you are currently taking.Dietary requirements e.g. vegetarian, vegan or allergies.(Required) I do not have any dietary requirements. I do have dietary requirements (Please provide details below) Please provide details of dietary requirements belowConsent(Required) To the best of my knowledge, the information I have provided is true and accurate CAPTCHA
