• Medical Consent & Indemnity

  •  -
  • Format: 0000 000 000.
  • Date of Birth*
     - -
  • What is your Gender?*

  • (Parent/Guardian – if under 18 years of age) hereby give permission for the Team Manager, or designated representative, 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:*
  • Blood Transfusion:*

  • (General Note: Parents/Guardians will be contacted, if possible, prior to any medical attention being given.)

  • Do you take regular medication?*

  • Have you ever had?
  • Have you ever had concussion?*
  • Have you ever had Head/Neck/Spinal injury?*
  • Have you had Fracture/Dislocation in last 3 years?*

  • Do you suffer from asthma?*

  • Do you have any medication allergies?*

  • Health Insurance Information

    Please complete where applicable
  • Do you have Ambulance Cover?*
  • Do you have Private Health Insurance?*
  • Type of cover

  • Emergency Contact Details

    Team Members are requested to list at least 1 emergency contact
  • Should be Empty: