Medical Form

PLAYERS MEDICAL FORM 2011/ 2012

PLAYERS FULL NAME .............................................................................AGE GROUP...............

FULL ADDRESS ..................................................................................................................………

DATE OF BIRTH ............/............./.............. TELEPHONE NUMBER  ..............................……...

PARENT / GUARDIAN NAME ..................................................................................................…..

TELEPHONE NUMBER IF DIFFERENT FROM ABOVE .......................................................…….

EMERGENCY CONTACT NAME & TELEPHONE NUMBER

This name and number will be used ONLY if contact cannot be made with the parent or guardian, in a medical emergency. The following must be a relation or trusted neighbour.

NAME ...............................................................................……

TEL NUMBER- Home .......................................................Mob:………………….........................................

RELATIONSHIP TO PLAYER…………………………………………………...............................................................

CHILDS BLOOD GROUP  ……………………………………………….

ALLERGIES ETC

Is the Player allergic to any substance that may be administered by a qualified person

(Doctor/nurse) in an emergency situation (i.e. Anadin, Penicillin, Tetanus Injection).                      YES.... NO

If yes, please give details ..................................................................................................................

Does the player suffer any illness that they take constant medication for? (Asthma, Epilepsy etc)   YES.... NO

If yes, please give details ..............................................................................................................................

Have you supplied the team manager with medication (i.e. Asthma inhaler)...?                             YES.... NO

Please Note: If you do submit any medication, this must be clearly labelled with the players name & date of birth.

NAME & ADDRESS OF THE PLAYERS DOCTOR

....................................................................................................................................................................................................................................................................................................

I agree that in the event of a medical emergency the above details can be made known to qualified medical personnel

PLAYERS SIGNATURE. ……………………………………………..….……………................ ............

.

PARENT / GUARDIAN SIGNATURE…………………………………

Date……………………………………………….