GWO Health Questionnaire/GWOPlease select the “YES” or “NO” field on the right as the item listed applies to your health or not.
If “YES” applies to your helath status, please describe in line ⑩. （example、[②Antihypertensive medication; Alderat CR20]、「④Hypertension」）ItemYES

NO① Have you been under surgical intervention/Hospitalization now or recently?

□□② Do you currently take medication that may impair you during training?

□□③ Have you suffered from diseases related to respiratory the system

□□□

□□□□

□□

□(Including asthma, pneumothorax, emphysema etc.)?
④ Have you suffered from cardiovascular diseases such as angina pectoris,myocardial infarction, hypertension, arrhythmia?
⑤ Do you have any conditions (including paralysis, joint diseases and rheumatism)such as a motor function that prevents movement during training and that may inaddition affect wearing a helmet or a life jacket?
⑥ Do you have any conditions related to otolaryngology (including otitis media,external auditory meititis, hearing loss, sinusitis)?
⑦ Do you have any conditions related to the nervous system (including epilepsy,depression, anxiety, panic syndrome and other neurosis)?
⑧ In addition to the above, please answer the following・

Skin conditions and allergies□□・Conditions related to digestive system such as gastrointestinal tract□□・

Conditions related to amblyopia or other eye conditions□□・Dizziness, lightheadedness□□・(Near) Drowning experience□□・

Fear of water□□・Fear of height□□MonthDay⑨ Last scheduled physical exam, within one year:※Please send a copy if there were any abnormal findings that may affect training.
⑩ If you have any concerns regarding the above or other information that may be aconcerning for this training, please state here.

⑪ Please select the best description below concerning your swimming ability:□I can swim

I verify that the aboveis true

□I am not a strong swimmerYearSignature:

MonthDay□I cannot swim

GWO Basic Training Self-Declaration of FitnessPersonal health shall be managed as your own responsibility and the training provider shall not bear anyresponsibility for injuries/ illnesses during and after training.
This health declaration form must be completed and submitted to the training provider before the commencementof training.

NameCompany’s Name

The following conditions may pose life threatening risk when participating in GWO basic safety training.

Asthma and other respiratory diseasesEpilepsy, fainting, and other similar conditionsAngina and other heart complicationsDizziness and other inner ear disturbances (difficulty of equilibrium, etc.)Fear of closed spaces and/or High PlacesBlood pressure disordersDiabetesPacemakers and implantable defibrillatorsMusculoskeletal disorders, arthritis, osteoarthritis and/or other movement restrictionsHistory of allergies (eg bees, spiders and other bites or stings)Under surgical intervention/Hospitalization now or recentlyOther health conditions that may be affected by physical stresses due to climbingI understand that the above conditions are health conditions which may pose life-threatening risks during trainingand declare here that I am of a healthy body and that I can participate in GWO basic safety training.

I declare that there are no factors to impede participation in GWO basic safety training or affect the execution oftraining.

I agree to follow all instructions during training period of the instructor.

If there is any doubt by the training provider concerning my health status, I understand that the training provider willstop training and seek advice from a doctor.

NameDate

GWO Training Consent Form/GWO 訓練に関する同意書1.

I understand that I will be involved in the following activities that take place during training:（1）Sea Survival Training with life vests (water entry from 1m, swimming, climbing in/out of a liferaft from water, winched from water by rescue strop (Module: Sea Survival).

（2）First Aid Training including CPR (Cardio Pulmonary Resuscitation) (module: first aid)（3）Initial fire fighting training using fire extinguishing equipment (Module: fire fighting and fireprevention)（4）Evacuation from a smoke filled space. (Module: fire fighting and fire prevention)（5）lifting/carrying a 15kg weight and the transport of a 30kg dummy. (module: manual handling)（6）evacuation and rescue equipment handling at a height of up to 12. (module: high altitudework)2.

I understand there are risks associated with this training and I take full responsibility for anyinjuries and/or losses that may occur to me or others due to my negligence during training

3.

I enter into this training with a positive attitude and responsibility towards the health andsafety of others.

4.

I understand that I will not obtain my certificate if I do not participate in all sections of thistraining (Lecture and Practical).

5.

I give the staff full permission without repercussion from me or anyone associated to me toadminister First Aid and will follow all directions given in the event of an emergency

Expected date of training: YM

D～YDate：YMMDDSignature:※ You may elect to not participate in any part of this training even though all aspects of this trainingmust be completed to fulfill the required assessment. This includes but not limited to the lecture,Test and practical application sections.

Your Privacy Matters to UsAt NSTC (Nippon Survival Training Center), we are committed to protecting your privacy. We respect your privacyand want you to understand how we safeguard your personal information.
How We Collect Your InformationWe collect and keep information about you, which is needed to provide the products and services you request. Wecollect information from you, either directly or through your company’s representatives.
How We Use Your InformationWe use your personal information to provide the products and service you or your company requests, whichincludes:•

Creating training certificates•Maintaining a record in our training database•

Creating invoices and receipts

We may be required to share or distribute your personal information to third party organizations that require yourinformation in order for NSTC to issue certification.
•The Certification Body of specific training•Insurance company•Your employer•Relevant company requiring your training history

We may use your information internally to create statistical reports that help us understand the needs of our clientsand help us manage our business.
SecurityNSTC will not release your personal information to any person or organization that is not reasonably involved in thedelivery of your requested service or product.
•Paper files containing your personal information are secured (locked storage) as soon as processing iscompleted.

•These files are kept for a period of five years and then destroyed.

Electronic files are backed up daily. If not updated, your personal information will automatically bedeleted after five years.

Your Right to Access Your InformationYou have a right to access the personal information that we have about you in your file.
is not correct, you can have it corrected.

If we have information thatTo access your information or to ask us to correct information, you cancontact us at:•2-6-27Ginza, Tobata-ku, Kitakyushu-shi, Fukuoka-ken, 804-0076, Japan•TEL : +81-93-884-2020•info@n-s-t-c.comor in person / writing

ConsentDo you understand and consent to Nippon Survival Training Center gathering your personal information for thepurposes described above?

Print Name:

Signature:

If yes, please sign below.

Date:Concent form for Training on Infection AgreementI understand the following conditions regarding infection order to join the training（1） The training may be cancelled or partially cancelled due to any situation including spread ofinfection, test positive for infection, or any other unavoidable reasons.
（2） In case the training is cancelled due to (1) above, delegates who have not completed thetraining will attend the same training planned alternately by NSTC at a later date. If the alternativetraining dates are not available, the course fee will be refunded. No refunds will be made for expensesother than the course fee (travel, accommodation, etc.).
（３） If you are infected with infection or suspected to be infected as having following symptoms,(Current or recurrent onset of cold-like symptoms such as fever, cough, sore throat, taste disorder,etc.) you will not be allowed to participate in the training.
(4) If you are found to be in poor health condition during the course (fever of 37.5℃ or higher,cold-like symptoms, etc.), you will not allowed to attend the training.

Training CourseExpected date oftraining

年

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年

⽉⽇Company NameName(PrintSignature)ver.2023.05.08