Swillington ARLFC Junior Player Medical History

Swillington ARLFC Junior Player Medical History
Please note that this is not a release of liability or waiver of any sort. This is a form to help the coaches and first aiders of the Swillington ARLFC better handle any future injury the player may incur while playing the sport of rugby league. It is necessary that this information is shared with medical professionals in the event of a serious on-pitch injury. This information will also help the coaches and first aiders understand any medical problems the player may have, whether it's asthma or a heart condition. Within the team, the only people who will have access to this information are the management team, coaches and first aiders.

If you have any questions regarding the completion of this form, please contact any of the coaches at Swillington ARLFC or email us on swillington.arlfc@aol.co.uk
Player Name*

First NameLast Name
Player Birth Date*

DayMonthYear
Your Name*

First NameLast Name
Your Relationship to Player*
Emergency contact name*
Emergency contact phone number*
Emergency contact relationship*
Please list any allergies - medication, food, pollen, etc
If they have an epi-pen, please note that and where they keep it.
Have they had in the past or do you currently have any of the following: (check any that apply)

AnemiaAsthmaDiabetesEpilepsy/SeizuresFainting SpellsHeart DiseaseHeart AttackHigh Blood PressureKidney DiseaseLiver DiseaseNeurological DisordersBleeding DisordersLung DiseaseNone
If you answered yes to any of the above, please provide details you feel are relevant.
If they currently have asthma: is it sport induced, do they have an inhaler, and what medication is in the inhaler?
Please list any medications, prescription or non-prescription, that they take regularly.
Please include multivitamins, nutritional supplements, naturopathic medications, etc.
Please list any previous sports injuries, approximate dates, and whether or not it is still a problem.
Do they have a family history of heart disease or stroke?*

YesNo
Do they have all of their paired organs (kidneys, lungs, eyes, etc)?*

YesNo
If they do not have all their paired organs, what are they missing?
Have they ever (to your knowledge) had a concussion/concussions?*

YesNo
If they have had a concussion or concussions, please list the date(s) and circumstance(s) as accurately as possible.
Are their pupils the same size?*

YesNo
Please share any other details you feel are relevant.
Do you consent to have this information shared with the Swillington ARLFC coaches and first aiders and if necessary paramedics, or hospital staff?*

Yes
Signature*

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