GWO Course Enrolment Form

MEDICAL SELF-ASSESSMENT FORM

This is an important document — please read it carefully before signing as you are accepting sole responsibility for your own health and medical condition and absolving 5th Point, its member companies, and their respective personnel, GWO training instructors and assessors (together referred to as  Providers) from any liability.

GWO candidates should be physically fit and unaffected by any medical condition that may prevent them from undertaking their training requirements or performing manoeuvres required during practical assessments.

Declaration

I declare that I am in good health, physically fit and consider myself suitable to undertake GWO training. I agree to follow all instructions from the appointed instructor for the duration of the GWO training course. I do not have any medical conditions or contra-indications that may prevent me from working safely. Should there be any doubt regarding my medical fitness, the training provider will stop the training and seek a physician’s advice.

Principal contra-indications to GWO training include (but are not limited to):

• prescribed medication that may impair physical and/or mental function;
• alcohol or drug dependence;
• diabetes, high or low blood sugar;
• high or low blood pressure;
• epilepsy, fits or periods of unconsciousness, e.g. blackouts;
• vertigo, giddiness or difficulty with balance;
• heart disease or chest pain;
• impaired limb function;
• musculoskeletal issues, e.g. back pain;
• psychiatric illness;
• fear of heights;
• claustrophobia/acrophobia (fear of enclosed spaces/heights);
• known allergies;
• recent surgery;
• sensory impairment, e.g. blind, deaf.

Risk and Disclaimer of Liability

I understand that GWO training and assessment in respect of it, carries risk to myself and others of personal injury (including permanent disability and death) because of the possibility of falls and collisions and is a strenuous activity.

On behalf of myself and my estate, I irrevocably release the Providers and their officers and personnel from any and all liabilities, claims, demands and expenses including legal fees arising from or in connection with my undertaking GWO training and assessment involved in applying for GWO certification.

By signing this declaration, I warrant and acknowledge that:

1. the information given by me is correct and will be relied upon by the Providers;
2. to the best of my knowledge and belief, engaging in GWO training activities would not be detrimental to my health, wellbeing or physical condition or to others who may be affected by my acts or omissions;
3. a GWO instructor has the right to exclude me from training or assessment if they have concerns over my health, fitness or attitude to safety;
4. (save where the Providers cannot exclude their liability by law), I accept that this Medical Self-Assessment Form remains legally binding even if the warranties and declaration given by me are untrue and I accept the risks involved in undertaking the training and assessment; and
5. I will advise 5th Point should my health or vulnerability to injury change and immediately cease GWO training activities unless approved to do so by a medical doctor.

This Medical Self-Assessment Form shall be construed and governed in accordance with Australian law and the parties submit to the exclusive jurisdiction of the Australian courts.