Ausome Hoops Diamond Valley Term 4
Sunday's 12:30pm - 1:15pm at Diamond Valley Sport and Fitness Centre. 15th October - 10th December (No session 22nd Oct)
Name
*
First Name
Last Name
Gender
*
Date of Birth
*
-
Day
-
Month
Year
Date
Email
*
example@example.com
Participant NDIS Number
*
For Invoicing Purposes
Formal Diagnoses:
*
Please help us get to know your child (e.g. likes/dislikes, favourite things)
Medical Information
Does your child have any of the following
Asthma
Diabetes
Allergies
Epilepsy
If Other was selected, please state:
Does your child use any regular medication?
Yes
No
If Yes was selected, please provide details
If you have selected 'Yes' to either Asthma or Allergies you must submit an Asthma or Allergy Management Plan. Participants will not be permitted to play until this information has been submitted
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Consent to Medical Treatment
I authorise officials, coaches and team managers to obtain for my child any necessary medical treatment by appropriate medical practitioners in the event of injury in my absence and where impractical to communicate with me. Should it be necessary to call an ambulance for my child, I accept full responsibility for any cost incurred.
Signature
*
Media Consent
I give permission to Ausome Hoops and Diamond Valley to take photographs and videos of my child during sessions for use on Social Media and for Marketing purposes.
Media Consent:
*
Yes
No
Signature
Contact Details
Contact Name 1
*
First Name
Last Name
Contact Number 1
*
Contact Name 2
*
First Name
Last Name
Contact Number 2
*
Payment
We have flexible payment options available. Please email director@ausomehoops.com.au to discuss.
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Ausome Hoops Diamond Valley
$
350.00
AUD
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