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224 lines
32 KiB
Plaintext
224 lines
32 KiB
Plaintext
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\red128\green0\blue128;\red128\green0\blue0;\red128\green128\blue0;\red128\green128\blue128;\red192\green192\blue192;}{\stylesheet{\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0
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\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 \snext0 Normal;}{\s1\qc \li0\ri0\keepn\widctlpar\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin0\lin0\itap0 \fs28\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 \sbasedon0 \snext0
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heading 1;}{\*\cs10 \additive Default Paragraph Font;}{\*\cs15 \additive \ul\cf2 \sbasedon10 Hyperlink;}{\s16\qc \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs28\lang2057\langfe1033\cgrid\langnp2057\langfenp1033
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\sbasedon0 \snext16 Title;}{\*\cs17 \additive \fs20\loch\f28\hich\af28\dbch\af28 \sbasedon10 HTML Code;}{\s18\ql \li0\ri0\widctlpar
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\tx916\tx1832\tx2748\tx3664\tx4580\tx5496\tx6412\tx7328\tx8244\tx9160\tx10076\tx10992\tx11908\tx12824\tx13740\tx14656\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0
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\fs20\cf1\lang2057\langfe1033\loch\f28\hich\af28\dbch\af28\cgrid\langnp2057\langfenp1033 \sbasedon0 \snext18 HTML Preformatted;}}{\info{\author }{\operator }{\creatim\yr2007\mo5\dy4\hr17\min14}{\revtim\yr2007\mo5\dy12\hr10\min45}{\version6}{\edmins72}
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{\nofpages3}{\nofwords427}{\nofchars2436}{\*\company }{\nofcharsws0}{\vern8247}}\paperw11906\paperh16838 \widowctrl\ftnbj\aenddoc\noxlattoyen\expshrtn\noultrlspc\dntblnsbdb\nospaceforul\hyphcaps0\formshade\horzdoc\dgmargin\dghspace180\dgvspace180
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\dghorigin1800\dgvorigin1440\dghshow1\dgvshow1\jexpand\viewkind1\viewscale100\pgbrdrhead\pgbrdrfoot\splytwnine\ftnlytwnine\htmautsp\nolnhtadjtbl\useltbaln\alntblind\lytcalctblwd\lyttblrtgr\lnbrkrule \fet0\sectd
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\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl {\*\pnseclvl1\pnucrm\pnstart1\pnindent720\pnhang{\pntxta .}}{\*\pnseclvl2\pnucltr\pnstart1\pnindent720\pnhang{\pntxta .}}{\*\pnseclvl3\pndec\pnstart1\pnindent720\pnhang
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{\pntxta .}}{\*\pnseclvl4\pnlcltr\pnstart1\pnindent720\pnhang{\pntxta )}}{\*\pnseclvl5\pndec\pnstart1\pnindent720\pnhang{\pntxtb (}{\pntxta )}}{\*\pnseclvl6\pnlcltr\pnstart1\pnindent720\pnhang{\pntxtb (}{\pntxta )}}{\*\pnseclvl7
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\pnlcrm\pnstart1\pnindent720\pnhang{\pntxtb (}{\pntxta )}}{\*\pnseclvl8\pnlcltr\pnstart1\pnindent720\pnhang{\pntxtb (}{\pntxta )}}{\*\pnseclvl9\pnlcrm\pnstart1\pnindent720\pnhang{\pntxtb (}{\pntxta )}}\pard\plain
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\s16\qc \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs28\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {Cambridge Austrian Cave Science Expedition 2007
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\par }\pard\plain \ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {
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\par The prompt return of a paper copy of this form is encouraged. The deadline for this is Friday 1}{\super st}{ June. Please enclose a deposit cheque for \'a3
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120 (payable to CU Caving Club Expo), unless you are to incur a large expo expense in advance of the trip (e.g. ferry tickets). This deposit is refundable only in circumstances deemed by the Expedition Leader to be exceptional.
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\par
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\par Please do not hesitate to contact me (as Expo Treasurer) or Aaron Curtis (as Expo Leader) with any queries.
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\par
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\par Thanks,
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\par
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\par }\pard \ql \li0\ri0\widctlpar\tqr\tx8306\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {Richard Mundy\tab r.c.mundy.03@cantab.net
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\par Magdalene College\tab 07906 362313
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\par }\pard \ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {Cambridge
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\par CB3 0AG
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\par
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\par }\trowd \trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth8568\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3
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\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2448 \cellx2340\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
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\cltxlrtb\clftsWidth3\clwWidth6120 \cellx8460\pard \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {Full name:\cell
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\par \cell }\pard \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\trowd \trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
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\trftsWidth3\trwWidth8568\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2448 \cellx2340\clvertalt\clbrdrt
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\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth6120 \cellx8460\row }\trowd \trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10
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\trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth8568\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
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\cltxlrtb\clftsWidth3\clwWidth2448 \cellx2340\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth6120 \cellx8460\pard
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\ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {Date of birth:\cell
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\par \cell }\pard \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\trowd \trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
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\trftsWidth3\trwWidth8568\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2448 \cellx2340\clvertalt\clbrdrt
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\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth6120 \cellx8460\row }\pard \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {E-mail address:\cell
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\par \cell }\pard \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\trowd \trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
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\trftsWidth3\trwWidth8568\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2448 \cellx2340\clvertalt\clbrdrt
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\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth6120 \cellx8460\row }\pard \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {Phone number(s):\cell
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\par
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\par \cell }\pard \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\trowd \trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
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\trftsWidth3\trwWidth8568\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2448 \cellx2340\clvertalt\clbrdrt
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\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth6120 \cellx8460\row }\pard \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {Address(es):\cell
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\par
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\par
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\par
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\par
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\par
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\par \cell }\pard \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\trowd \trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
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\trftsWidth3\trwWidth8568\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2448 \cellx2340\clvertalt\clbrdrt
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\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth6120 \cellx8460\row }\pard \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {
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Reason for not enclosing a deposit, if this is the case:\cell \cell }\pard \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\trowd \trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr
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\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth8568\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
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\cltxlrtb\clftsWidth3\clwWidth2448 \cellx2340\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth6120 \cellx8460\row }\pard
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\ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {Next of kin\rquote s name:\cell
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\par \cell }\pard \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\trowd \trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
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\trftsWidth3\trwWidth8568\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2448 \cellx2340\clvertalt\clbrdrt
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\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth6120 \cellx8460\row }\pard \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {Next of kin contact number(s):\cell
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\par
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\par \cell }\pard \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\trowd \trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
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\trftsWidth3\trwWidth8568\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2448 \cellx2340\clvertalt\clbrdrt
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\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth6120 \cellx8460\row }\trowd \trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10
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\trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth8568\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
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\cltxlrtb\clftsWidth3\clwWidth2448 \cellx2340\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth6120 \cellx8460\pard
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\ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {Next of kin address:\cell
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\par
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\par
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\par
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\par
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\par
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\par \cell }\pard \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\trowd \trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
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\trftsWidth3\trwWidth8568\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2448 \cellx2340\clvertalt\clbrdrt
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\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth6120 \cellx8460\row }\pard \ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {
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Please continue on a second page if the fields provided are insufficient.\sect }\sectd \linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl \pard\plain
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\s1\qc \li0\ri0\keepn\widctlpar\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin0\lin0\itap0 \fs28\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {CUCC Expo 2007 \endash Insurance Details
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\par }\pard\plain \ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {
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\par The medical information submitted on this form will be seen only by Richard Mundy (r.c.mundy.03@cantab.net) and Serena Povia (}{\cs17\dbch\af28 \hich\af0\dbch\af28\loch\f0 sp422@cam.ac.uk}{
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). We will disclose this information to the insurers, but it will not be seen by anyon
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e else unless there is a risk of significant harm to yourself or others. If you would prefer just to have Serena see this information, you are invited to arrange to send the form directly to her. Serena is arranging the trip\rquote s insurance.
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\par
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\par }\trowd \trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth8568\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3
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\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3888 \cellx3780\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
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\cltxlrtb\clftsWidth3\clwWidth4680 \cellx8460\pard \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {Full name:\cell
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\par
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\par \cell }\pard \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\trowd \trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
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\trftsWidth3\trwWidth8568\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3888 \cellx3780\clvertalt\clbrdrt
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\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4680 \cellx8460\row }\trowd \trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10
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\trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth8568\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
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\cltxlrtb\clftsWidth3\clwWidth3888 \cellx3780\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4680 \cellx8460\pard
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\ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {Date of birth:\cell
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\par
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\par \cell }\pard \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\trowd \trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
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\trftsWidth3\trwWidth8568\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3888 \cellx3780\clvertalt\clbrdrt
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\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4680 \cellx8460\row }\pard \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {
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Do you already have appropriate medical/rescue insurance?\cell
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\par
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\par \cell }\pard \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\trowd \trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
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\trftsWidth3\trwWidth8568\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3888 \cellx3780\clvertalt\clbrdrt
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\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4680 \cellx8460\row }\pard \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {Would you like possessions insurance?
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\cell
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\par
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\par \cell }\pard \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\trowd \trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
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\trftsWidth3\trwWidth8568\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3888 \cellx3780\clvertalt\clbrdrt
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\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4680 \cellx8460\row }\pard\plain \s18\ql \li0\ri0\widctlpar\intbl
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\tx916\tx1832\tx2748\tx3664\tx4580\tx5496\tx6412\tx7328\tx8244\tx9160\tx10076\tx10992\tx11908\tx12824\tx13740\tx14656\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \fs20\cf1\lang2057\langfe1033\loch\af28\hich\af28\dbch\af28\cgrid\langnp2057\langfenp1033 {
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\f0\fs24 \hich\af0\dbch\af28\loch\f0 Are you waiting for an operation, a non-routine hospital consultation, are you HIV positive? }{\f0\fs24\cf0 \hich\af0\dbch\af28\loch\f0 Do you have a terminal prognosis from a doctor?}{\f0\fs24 \cell }\pard\plain
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\ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {
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\par
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\par
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\par
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\par
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\par
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\par
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\par
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\par \cell }\pard \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\trowd \trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
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\trftsWidth3\trwWidth8568\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3888 \cellx3780\clvertalt\clbrdrt
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\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4680 \cellx8460\row }\pard\plain \s18\ql \li0\ri0\widctlpar\intbl
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\tx916\tx1832\tx2748\tx3664\tx4580\tx5496\tx6412\tx7328\tx8244\tx9160\tx10076\tx10992\tx11908\tx12824\tx13740\tx14656\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \fs20\cf1\lang2057\langfe1033\loch\af28\hich\af28\dbch\af28\cgrid\langnp2057\langfenp1033 {
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\b\f0\fs24\cf0 \hich\af0\dbch\af28\loch\f0 In the last 12 months:}{\f0\fs24\cf0 \hich\af0\dbch\af28\loch\f0
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Have you been medicated for a blood disorder, psychiatric illness or any cancer? Have you received a transplant or dialysis? Have you been treated in hospital for any heart or\hich\af0\dbch\af28\loch\f0 breathing problem?\cell }\pard\plain
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\ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {
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\par
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\par
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\par
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\par
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\par
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\par
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\par
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\par \cell }\pard \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\trowd \trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
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\trftsWidth3\trwWidth8568\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3888 \cellx3780\clvertalt\clbrdrt
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\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4680 \cellx8460\row }\trowd \trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10
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\trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth8568\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
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\cltxlrtb\clftsWidth3\clwWidth3888 \cellx3780\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4680 \cellx8460\pard\plain \s18\ql \li0\ri0\widctlpar\intbl
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\tx916\tx1832\tx2748\tx3664\tx4580\tx5496\tx6412\tx7328\tx8244\tx9160\tx10076\tx10992\tx11908\tx12824\tx13740\tx14656\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \fs20\cf1\lang2057\langfe1033\loch\af28\hich\af28\dbch\af28\cgrid\langnp2057\langfenp1033 {
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\b\f0\fs24\cf0 \hich\af0\dbch\af28\loch\f0 In the last 3 months:}{\f0\fs24\cf0 \hich\af0\dbch\af28\loch\f0 Were you admitted overnight to a hospital? Have you been to a specialist for a non-routine consultation? \cell }\pard\plain
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\ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {
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\par
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\par
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\par
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\par
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\par
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\par
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\par
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\par \cell }\pard \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\trowd \trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
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\trftsWidth3\trwWidth8568\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3888 \cellx3780\clvertalt\clbrdrt
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\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4680 \cellx8460\row }\pard \ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {
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Please continue on a second page if the fields provided are insufficient\sect }\sectd \linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl \pard\plain
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\s1\qc \li0\ri0\keepn\widctlpar\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin0\lin0\itap0 \fs28\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {CUCC Expo 2007 \endash Medical Details
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\par }\pard\plain \ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {
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\par The medical information submitted on this form will be seen only by Richard Mundy (r.c.mundy.03@cantab.net) and Dr. Phil Underwood (phil@furbrain.org.uk). The information will not be disclosed to anyone else unless there is a ris
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k of significant harm to yourself or others. If you would prefer just to have Phil see this information, you are invited to arrange to send the form directly to him. Phil is our medic.
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\par
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\par }\trowd \trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth8568\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3
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\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3888 \cellx3780\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
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\cltxlrtb\clftsWidth3\clwWidth4680 \cellx8460\pard \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {Full name:\cell
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\par
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\par \cell }\pard \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\trowd \trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
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\trftsWidth3\trwWidth8568\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3888 \cellx3780\clvertalt\clbrdrt
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\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4680 \cellx8460\row }\trowd \trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10
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\trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth8568\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
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\cltxlrtb\clftsWidth3\clwWidth3888 \cellx3780\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4680 \cellx8460\pard
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\ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {Date of birth:\cell
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\par
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\par \cell }\pard \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\trowd \trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
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\trftsWidth3\trwWidth8568\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3888 \cellx3780\clvertalt\clbrdrt
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\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4680 \cellx8460\row }\pard\plain \s18\ql \li0\ri0\widctlpar\intbl
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\tx916\tx1832\tx2748\tx3664\tx4580\tx5496\tx6412\tx7328\tx8244\tx9160\tx10076\tx10992\tx11908\tx12824\tx13740\tx14656\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \fs20\cf1\lang2057\langfe1033\loch\af28\hich\af28\dbch\af28\cgrid\langnp2057\langfenp1033 {
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\f0\fs24 \hich\af0\dbch\af28\loch\f0 Do you have any medical conditions which may require medical attention
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\par \hich\af0\dbch\af28\loch\f0 while on expo (e.g. diabetes, epilepsy, asthma)?}{\f0\fs24\cf0 \cell }\pard\plain \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {
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\par
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\par
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\par
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\par
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\par
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\par
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\par
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\par
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\par
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\par \cell }\pard \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\trowd \trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
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\trftsWidth3\trwWidth8568\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3888 \cellx3780\clvertalt\clbrdrt
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\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4680 \cellx8460\row }\pard\plain \s18\ql \li0\ri0\widctlpar\intbl
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\tx916\tx1832\tx2748\tx3664\tx4580\tx5496\tx6412\tx7328\tx8244\tx9160\tx10076\tx10992\tx11908\tx12824\tx13740\tx14656\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \fs20\cf1\lang2057\langfe1033\loch\af28\hich\af28\dbch\af28\cgrid\langnp2057\langfenp1033 {
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\f0\fs24 \hich\af0\dbch\af28\loch\f0 Are you on any medication? If yes, what medication?}{\f0\fs24\cf13 \cell }\pard\plain \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {
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\par
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\par
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\par
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\par
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\par
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\par
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\par
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\par
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\par
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\par \cell }\pard \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\trowd \trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
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\trftsWidth3\trwWidth8568\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3888 \cellx3780\clvertalt\clbrdrt
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\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4680 \cellx8460\row }\trowd \trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10
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\trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth8568\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
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\cltxlrtb\clftsWidth3\clwWidth3888 \cellx3780\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4680 \cellx8460\pard\plain \s18\ql \li0\ri0\widctlpar\intbl
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\tx916\tx1832\tx2748\tx3664\tx4580\tx5496\tx6412\tx7328\tx8244\tx9160\tx10076\tx10992\tx11908\tx12824\tx13740\tx14656\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \fs20\cf1\lang2057\langfe1033\loch\af28\hich\af28\dbch\af28\cgrid\langnp2057\langfenp1033 {
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\f0\fs24 \hich\af0\dbch\af28\loch\f0 Do you have any allergies?}{\f0\fs24\cf13 \cell }\pard\plain \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {
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\par \cell }\pard \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\trowd \trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
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\trftsWidth3\trwWidth8568\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3888 \cellx3780\clvertalt\clbrdrt
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\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4680 \cellx8460\row }\pard \ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {
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\par }} |