GT 2023 State SquadTeam - Medical Consent and Indemnity Form

Medical Consent & Indemnity

State Squad/State Team 2023
State Squad Members: Please complete Medical Consent and Indemity form.

State Team Members: Please complete one Medical Consent and Indemnity form per Team Member travelling to the Australian Gymnastics Championships with your nomination, or by 29th March, 2023. If you have already completed as a State Squad Member for 2023, you do not need to complete again.
Club*
Full Name*

First NameLast Name
Gymsport*

MAGWAGTRPRG
Position

GymnastOfficial
E-mail*
Phone*
Date of Birth*

DayMonthYear
What is your Gender?*

MaleFemale
I,*
Name
(Parent/Guardian – if under 18 years of age) hereby give permission for the Team Manager or coach, to seek medical aid in the event of an accident, injury or illness. General medical aid, including transport, will be at the discretion of the Manager or designated representative.

In addition:

Specific permission, on appropriate medical advice is given for the following:
General Anasthesia:*

YesNo
Blood Transfusion:*

YesNo
Traumatic injury requiring immediate surgery:*

YesNo
(General Note: Parents/Guardians will be contacted, if possible, prior to any medical attention being given.)
Blood Group
Do you Object to Blood Transfusions*

YesNo
Do you take regular medication?*

YesNo
If Yes, please list
Are there any relevant mental health issues to be aware of?
Have you ever had?

Epilepsy/ConvulsionsHepatitis/JaundiceDiabetesHeart Problem/MurmurEar Problems/InfectionsStomach Problems
Have you ever had concussion?*

YesNo
Number of times
Approx date of last concussion

DayMonthYear
Have you ever had Head/Neck/Spinal injury?*

YesNo
If yes, please provide details
Have you had Fracture/Dislocation in last 3 years?*

YesNo
If yes, please provide details
Vision/Asthma
Do you wear glasses?*

YesNo
Do you wear contact lenses?*

YesNo
What type of contacts do you use?

HardSoft
Do you suffer from asthma?*

YesNo
Do you ever take medication for asthma?*

YesNo
If yes, please provide details
Do you bring your medication to training/competition?*

YesNo
Are there any relevant mental health issues to be aware of?
Vaccinations/Allergies
Have you been vaccinated against?

Hepatitis AHepatitis BTetanus
Are you allergic to?

TapeIce
Are you allergic to any types of food?*

YesNo
If yes please list
Dietary Requirements
Do you have any medication allergies?*

YesNo
If yes please list
Do you carry an EPIPEN
If YES, for what allergy?
Health Insurance Information

Please complete where applicable
Medicare Number*
Do you have Ambulance Cover?*

YesNo
Do you have Private Health Insurance?*

YesNo
Name of Fund
Type of cover

BasicIntermediateTop
Member Number
Extra cover for Physiotherapy?

YesNo
Coverage for overseas?

YesNo
Emergency Contact Details

Team Members are requested to list at least 1 emergency contact
Contact Person 1*
Contact Number*
Relationship*
Contact Person 2
Contact Number
Relationship
I Agree (Self/Parent/Guardian)*

I have read, understood, acknowledge and confirm that the information is true and correct
Full Name*

First NameLast Name
Should be Empty:

Medical Consent & Indemnity

Health Insurance Information

Emergency Contact Details