Raku Waiver Form

Participant Information

Name

First Name *

Last Name *

Date of birth *

Day *

Month *

Year *

Address

Address 1 *

Address 2

City *

Postal Code *

Daytime telephone no. *

Email address *

Have you a history or receive medication for any of the following:

 Select as approppriate

Asthma

Diabetes

Epliepsy

Stroke / Heart Attack

More info on the above or other medical conditions not listed

Name

First Name *

Last Name

Phone Number *

I confirm that I have read the Raku Participant Responsibilities, Consent & Assumption of Risk and fully understand and agree to them.

Select date *

Day *

Month *

Year *