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Health and Insurance Questionnaire

Please fill in the form below. If you have any questions please get in touch

Step 1 of 5

20%

Which challenge are you taking part in(Required)

The MoonWalk Iceland

Nijmegen Marches

Camino 100

Camino Portugués

Camino Journey to the Edge of the World

New York Marathon

Name(Required)

First name Surname

Email(Required)

Enter Email Confirm Email

Mobile phone(Required)

Date of Birth(Required)

DD slash MM slash YYYY

Emergency contact name (This must be someone who is NOT on the challenge with you)(Required)

First name Surname

Emergency contact mobile number(Required)

Emergency contact relationship to you(Required)

Name of Insurance Company(Required)

Policy Number(Required)

24 Hour Medical Assistance Phone Number(Required)

Insurance Company Contact Number(Required)

Do you suffer from Asthma? ((Required)

Yes

No

Please give us more detail(Required)

Do you smoke?(Required)

Yes

No

Do you consider yourself to have a disability?(Required)

Yes

No

Please give us more detail(Required)

Have you developed chest pains in the last month?(Required)

Yes

No

Please give us more detail(Required)

Has a doctor ever said that you have a heart condition and recommended only medically supervised activity?(Required)

Yes

No

Please give us more detail(Required)

Do you lose consciousness or fall over as a result of dizziness?(Required)

Yes

No

Please give us more detail(Required)

Do you have any bone or joint problems that could be aggravated by physical activity?(Required)

Yes

No

Please give us more detail(Required)

Has a doctor ever recommended medication for your blood pressure or heart condition?(Required)

Yes

No

Please give us more detail(Required)

Are you aware through your own experience, or from a doctor's advice, of any reason why you should not exercise without medical supervision?(Required)

Yes

No

Please give us more detail(Required)

If there is any other information you feel may be relevant, please let us know here

Do you have any dietary requirements including those relating to medical conditions or allergies?(Required)

Yes

No

Please note: we can only cater for lifestyle dietary choices or those relating to medical conditions or allergies, we cannot cater for dietary preferences.

Please give us more information(Required)

Consent

I agree

By submitting this online form to Walk the Walk, you declare that you have completed the details to the best of your knowledge, that you are eighteen years of age or over and physically fit to undertake such a challenge. You understand that you are responsible for monitoring your own physical condition, and should you develop a condition that affects your ability to walk, you will inform the Walk the Walk Team immediately.

Email

This field is for validation purposes and should be left unchanged.

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©Walk the Walk Worldwide 2025

Walk the Walk Worldwide is a company limited by guarantee which is registered in Scotland under number SC201169 and registered as a charity with the Office of the Scottish Charity Regulator under number SC029572. Registered office: 5 Atholl Crescent, Edinburgh, Midlothian, EH3 8EJ. Correspondence office: 6 Genesis Business Park Woking GU21 5RW. VAT No 800852848.

Patron His Majesty King Charles III

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