Under 16 Girls Indoor Hockey - HCC Medical Information Form for Junior Rep Players

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Name of Player: First Name and Surname*

Date of Birth*

Address*

Name of Parent/Guardian*

Mobile Phone:*

Alternate phone and name of contact person if parent/guardian cannot be contacted:

My child has been immunised against polio/diptheria/whooping cough

My child is currently immunised against tetanus

My child is allergic to the following medications

(Please list)

My child suffers from a particular illness/allergy (includes food allergies)

If yes, please state the illness/allergy and any medications he/she is currently taking and/or would need in an emergency

My child has been suffering from an illness/injury during the past month.

If yes, please indicate medication taken or physio/exercises required

Please list any other medical information you consider important ie: travel sickness etc

Medicare Number:

Name on Medicare card:

My child is covered by private medical/hospital insurance

Name of private medical fund:

Membership number:

My child is covered by Ambulance Cover

Ambulance Membership number:

Is there anything else you need to let us know?

By completing this form I acknowledge
In the event of any accident/illness, I authorise the obtaining on my behalf of such medical assistance my child may require.
I authorise the administering of an anaesthetic if medical officials attending to my child deem this necessary.
I agree to pay for any costs involved and understand that I shall be contacted immediately such medical treatment has been sought.
I authorise the information contained on this form to be provided to medical officials attending to my child.
I give permission for my child to take "panadol" in accordance with the dosage requirements stated on the medication packaging, in the event he/she may require this for the treatment of minor pains/aches.

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Under 16 Girls Indoor Hockey - HCC Medical Information Form for Junior Rep Players

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