MEDICAL DECLARATION for Bruce Boats SKIPPERS * MEDICAL DECLARATION for Bruce Boats SKIPPERS First Name First Name Last Name Last Name * I have a current ML5 certificate I have a current ENG1 certificate I have a current DVLA medical fitness form for HGV or PSV I don’t have any of the above Choose one of the following declarations: * I am in good health and do not suffer from any of the conditions listed below. I can read a car number plate at 20.5m distance (if using glasses, these will be worn on the boat at all times) I have one or more of the conditions listed below. I have discussed my fitness with my GP who confirms that I am not at high risk of incapacity, and am fit to carry out the duties of a Bruce Boats skipper. I can read a car number plate at 20.5m distance (if using glasses, these will be worn on the boat at all times) I am no longer fit enough to safely skipper a Bruce Boat I confirm that this declaration is correct to the best of my knowledge, and I will inform the Training Co-ordinator if my health changes significantly during the year * * Submit Medical Conditions List from the Small Passenger Boat Code 1. Epileptic seizures / disturbances of the state of consciousness 2. Coronary Thrombosis or Heart Surgery 3. Problems with hear rhythm, disease of the heart or arteries 4. High blood pressure uncontrolled by drugs 5. Diabetes controlled by insulin 6. Stroke or unexplained loss of consciousness in the last 5 years 7. Severe head injury with continuing effects 8. Parkinson’s disease or Multiple Sclerosis 9. Mental or nervous problems in the last two years 10. Alcohol or drug addiction in the last two years 11. Profound deafness – unable to use telephone or radio 12. Double or tunnel vision 13. Maligant brain tumour in the last five years 14. Any condition which would cause problems regarding your fitness to navigate a Trust vessel If you are human, leave this field blank.
