2025 WHSC Junior Course Medical & Emergency Contact Form

2025 Junior Course Medical & Emergency Contact Form

This form MUST be completed and returned before any booking can be accepted
Sailors Details
Sailors Name*
Date Of Birth*

DayMonthYear
Date
Address*

Street Address

Street Address Line 2

Town/CityCounty

Eircode
Emergency Contacts
Name of Parent/Guardian No. 1*

First NameLast Name
Relationship*
Contact Number*
Contact Email*
Name of Parent/Guardian No. 2*

First NameLast Name
Relationship*
Contact Number*
Contact Email*
Doctors Name*

First NameLast Name
Doctors Contact Number*
Medical Information
Does your child have any allergies to medication? - e.g. penicillin*

YesNo
If so... Which medication
Does your child have any other allergies?*

YesNo
If so... Please List
Does your child take any medication we should be aware of?*

YesNo
If so.. Please List
Is there any health condition, injury or any particular/special needs that we should be aware of in general for instructional, reading, comprehension & concerntration purposes or in the event of an accident or injury?*

YesNo
If so.. Please List
Please be assured this information is maintained in the strictest confidence and is shared only with the J.O.'s, S.I. & the instructor that is teaching your child.
Permission
I give my permission for basic first aid to be administered by a suitably qualified member of staff where considered necessary or by a qualified medical practitioner. I authorise a qualified medical practitioner to provide any treatment or medication deemed necessary. I declare that my child is physically fit to take part in the activities provided.*

YES
We declare that we have read & understood WHSC policy 005 "Members Code of Conduct Policy" and agree to adhear to the expectations outlined within and understand that diciplinary proceedings may occur if we do not comply.
Signature - Parent / Guardian*

Clear
Date

DayMonthYear
Date
Signature - Sailor*

Clear
Date

DayMonthYear
Date
Should be Empty:

2025 Junior Course Medical & Emergency Contact Form

Sailors Details

Emergency Contacts

Medical Information

Permission