Mountaineering / Rock Climbing Questionnaire

Name: «NAME» Ref: «Number»

1.  Please confirm which you take part in:-

Abseiling
Artificial Wall Climbing
Caving and Pot Holing
Hill Climbing
Ice and Snow Climbing
Mountaineering
Rock Climbing
Trekking
Other

If ‘other’ please give details…………………………………………………………………………………………….

2.  How many hours on average do you participate in this activity per year? ………………………..

3.  In which geographical areas do you take part in this activity?

UK If UK please state where ………………………………..………………………………….

Overseas If overseas please state where ………………………………………..………………..

If overseas please state length of trip(s) …………………………………………….

4.  At any time have you been injured as a result of your pastimes/hobbies referred to above?

Yes No

If ‘yes’ please complete the ‘injuries’ questionnaire overleaf.

Signed…………………………………………………………….. Date………………………………………

This questionnaire forms part of your application for membership of the Society.The Society would advise you to take care to include any material fact in this questionnaire.A material fact is one whichcould affect the terms of acceptance or the payment of any claim.If you do not tell us about a material fact this could lead to your application being declined and may result in any monies paid to the Society together with any claims made upon the funds thereof, being forfeited.If you are in any doubt as to whether a fact is material you should tell us about it as part of yourapplication.

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Mountaineering / Rock Climbing Questionnaire

Name: «NAME» Ref: «Number»

Injury / Which side of body
(if applicable) / Date / How did the injury occur? (e.g. RTA, through sport etc) / Was surgery required?
If so, when? / Have you received any other treatment (e.g. medication/
physiotherapy etc).
If so, please supply dates, durations, frequency) / Time off work (please provide
Dates & durations) / Is there any residual
pain/ stiffness/ discomfort? / Has a full recovery been made?

Signed………………………………………………………………………………………………………………………… Dated………………………………………………………………………………………..

Cirencester Friendly is a trading name of Cirencester Friendly Society Limited.

Registered and Incorporated under the Friendly Societies Act 1992. Reg. No. 149F.

Cirencester Friendly Society Limited is Authorised by the Prudential Regulation Authority and regulated by the

Financial Conduct Authority and the Prudential Regulation Authority under the registration number 109987.

Page 2 of 2 V1 (NOV 2014)