GCAS MEDICAL FORM

Academy Program participating in

GCAS Academy Program

Athlete Name

Given NamesSurname

Email

example@example.com

Sport/s

What sport do you play?

Address

Street Address

Street Address Line 2

CityState

Post Code

Emergency Contact Name:

Person to contact incase of emergency

Relationship to Athlete

Mobile Number

Alternative Contact Number

Name of Family Doctor

First NameLast Name

Doctors Number

Please enter a valid phone number.Format: (000) 000-0000.

Doctors Address

Street Address

Street Address Line 2

CityState

Post Code

Is your child covered by a Private Health Insurance Fund?

Name of Fund

Childs Medicare Number

Does your child suffer from any of the following?

If other, please specify

Just write N/A if none was chosen above

If any of the above have been selected, please outline the management

Just write N/A if none was chosen above

Please list any known allergies or conditions the GCAS should be aware of

Please list any physical (eg. muscular / joint problems) that may limit your child's physical activity

Just write N/A if none are known

Please give details of any major operations or surgical procedures the athlete has undergone in the last 2 years

Has your child suffered a concussion or a similar head injury in the last 3 years? Please supply details of treatment and outcomes.

Just write N/A if none are known

List any muscular / joint problems that may limit your child's physical activity: Please supply details of treatment and outcomes.

Just write N/A if none are known

Please provide information regarding regular or current medication. Medications brought to any Academy program must have the athlete's name, dosage, and dosage times clearly labeled. Only medication in the athlete's name will be administered.

Just write N/A if none are known

Has the athlete been fully immunised against tetanus?

What Year

Any athlete with a medical concern is required to produce a letter from His/Her doctor regarding the treatment of the condition.

Please provide the GCAS staff of any special dietary requirements by doctor's order and/or a list of food allergies and attach

Please attach any relevant documents outlining medical conditions.

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GOLD COAST ACADEMY OF SPORT - MEDICAL FORM