Member - Medical & Consent Form
Email
*
This will be used for contact, cascades/news, payment requests etc..
Member’s Name
*
Date of birth
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
RLSS Number
This is not mandatory for this form if this submission is your child coming to the club for their first time. However NO syllabus awards or accreditation can be given without The membership of the RLSS. Please resubmit a new form when your child becomes an RLSS member.
Specific Medical Conditions of which we should be aware (eg. asthma, seizures?)
*
If there are any conditions or special needs for your child then in addition to this narrative, please ensure to discuss this with the club instructors/admin so that it is considered within the Club's obligatory Risk Assessment of their needs (in accordance with RLSS Policies and Procedures). Thanks.
Allergic Conditions (eg. medication, food, other)?
*
Here are just some examples: nuts, penicillin, eggs
Have you had any serious injuries or illnesses in the past 12 months?
*
Date of last anti-tetanus jab
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Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Not mandatory - but may help if required by a medic/clinician.
Any other medical treatment being received at present?
*
Any treatment my child must NOT receive without my express consent?
*
Please express any specific medical treatments and/or pharmacology that you do NOT wish your child to receive.
Parents Name
*
Home Address
*
Please add full address incl. postcode.
Primary Contact Number
*
All contact (incl. WhatsApp news/cascades) and bill payments will be made to this number
Secondary Contact Number
*
In the event the primary cannot be reached.
Allow Club Photography
*
Yes
No
Doctor’s Name, Address and Phone Number
*
PLEASE TICK THE DECLARATION BELOW TO CONFIRM
*
In the event of illness or accident requiring emergency treatment I authorise a CLUB TEACHER/ADMIN to sign on my behalf any written form of consent required, except those listed under exceptions above, by medical authorities if the delay required to obtain my signature or authority is considered inadvisable by the medical authority officer(s) concerned.
Confirmed by Parent or Guardian/Carer
*
Parent
Guardian / Carer
Today’s date to confirm when signed
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Additional Info (or) Is this submission to notify the club of member changes?
*
This helps us understand if you are sending us an update eg. RLSS number, new medication or any additional narrative.
Submit
Should be Empty: