2023 Medical and social media form

2023 Medical Information and Social Media Permission

Player Form
Club*
Child / Junior Player's Name*

First NameLast Name
Child / Junior Player's Date of Birth*

MonthDayYear
Date
Parent / Guardian*

First NameLast Name
Parent / Guardian Mobile number*
E-mail*
example@example.com
Emergency Contact Details (if different to Parent / Guardian)

First NameLast Name
Relationship to Player (if different to Parent / Guardian)
Emergency Contact phone number (if different to Parent / Guardian)

Player Immunisation details*

Do you suffer from Asthma?*

Yes and I will provide the Club with the Asthma planNoYes but do not have a current Asthma plan
Please load the current Asthma Action Plan

Cancelof
Has the player suffered concussion in the last three years?*

YesNo
If Yes, supply details of treatment and outcomes*
Are there any other health conditions that the CHJRU should be aware of? (Diabetes, Epilepsy, Bronchitus, Allergies, Muscular/Joint problems or other) If Yes, please list with current management of the condition.
Does your child require regular medication or current medication? If Yes, please supply details.

Medicare Card number*
Child's Full Name*
Please enter the FULL NAME on the card
Number on Card*
Enter the number of the position the the player is placed on the Medicare card
Private Health Insurance Company Name (if covered)
Private Health Insurance Membership Number
Media Consent

As the Parent / Guardian {parent36} of {name} I give permission for CHJRU (and any Affilated Club) to take photographs and/or videos of {name} for use on all social media platforms which include but are not limited to the CHJRU and Club Facebook pages, CHJRU website, as well as traditional media such as the local newspaper.
YesNo
Medical Permission

I confirm that all of the information provided is current and accurate, and I will advise the CHJRU of any changes that occur during the season. We will meet all health and safety requirements in relation to COVID-19, including signing in and out at sporting events and training to assist with contract tracing, not attending if feeling unwell, practicing good personal hygiene, and following any directions supporting physical distancing.

I give permission for the CHJRU to seek medical aid if necessary for my child in the event of any injury or illness, and to arrange transport to the nearest hospital by ambulance. I understand any cost incurred will be paid by me and is not the responsibility of the CHJRU.
Parent / Guardian signature

Clear
Date*

MonthDayYear
Date
Should be Empty:

2023 Medical Information and Social Media Permission