EDMONTON JUNIOR RUGBY LEAGUE PLAYER MEDICAL FORM

EDMONTON JUNIOR RUGBY LEAGUE PLAYER MEDICAL FORM - CONFIDENTIAL
Name

Player First NamePlayer Last Name
Date of Birth

DayMonthYear
Date
TEAM:
What age group? Eg. U14, U8, U12
Address

Street Address

Street Address Line 2

CityState

Post Code
Name of Medical Centre
Name of Doctor
MEDICARE NUMBER
Number & number next to player's name eg. 1, 2, 3, 4
Exp Date
EMERGENCY CONTACT PERSON:
Contact Persons Name
Relationship to player
Contact Phone Number
Format: (00) 000-00000.
I give permission to call an ambulance in an emergency.
Does your child suffer from any Medical Conditions?
Diabetes:
How is this managed?
Asthma:
How is this managed?
Epilepsy:
How is this managed?
Bronchitis:
How is this managed?
Allergies:
How is this managed?
Heart Conditions:
How is this managed?
Anxiety/Depression:
How is this managed?
Does your child experience any of the following during training/playing?
Unusual shortness of breath?
How is this managed?
Chest Pain?
How is this managed?
Light-headedness, dizziness or fainting?
How is this managed?
Become tired/fatigued easily?
How is this managed?
Anxiety attacks?
How is this managed?
Any other conditions the club should be aware of?
Conditions
Please write conditions and how it is treated.
Any regular medication?
Doses & Times
Any physical issues that may affect your child's physical activity? eg. muscular/joint
Physical issue:
Has your child suffered a concussion in the last 3 years?
Please supply details of date, treatment & outcome:
I am aware of and understand that there are inherent risks associated with participating in the physical activity of rugby league.

I declare this to be a true statement of my child's health status as at the date below and I will inform the Club and the Team Manager/Sports Trainer of any changes to this information during the season.
Parent/Guardian Name
Signature
Date

DayMonthYear
Date
PLAYER MEDICAL FORM - CONFIDENTIAL
The standard Medical Form for all Junior Rugby League players is meant to assist those who Coach and care for your child/children during the season in providing (as far as humanly possible) a safe training and playing environment for your child. It is also meant to provide information to you, as a parent/guardian, information about any injury or condition your child may have so that he/she can participate safely and enjoy the game of Rugby League.

This form is not meant to be in any way an invasion of the privacy of your child, nor will it be given to any other person unless you give permission to do so.

The only people who will access this form will be the appointed Rugby League First Aid Officer, your child's Team Manager, your private doctor and/or qualified personnel employed by the Queensland Ambulance Service (QAS) who may be given this information to support the care and medical treatment of your child in the case of a serious injury.

DECLARATION:

I acknowledge that the information contained on the Medical Form required by Edmonton Junior Rugby League and its governing organisations is only to be used for the safe treatment of my child in the event of a medical incident during official training sessions and sanctioned games.

I understand that the Medical Form is only helpful to my child if it is completed honestly and accurately each year.

I declare that the information contained on the Medical Form about my child is accurate to the best of my knowledge.

I accept that this information will only be used for the safe treatment of my child and accessed only by those required to provide safe treatment as mentioned above.
Parent/Guardian Name
Parent/Guardian Signature
Date

DayMonthYear
Date
Should be Empty:

EDMONTON JUNIOR RUGBY LEAGUE PLAYER MEDICAL FORM - CONFIDENTIAL

EMERGENCY CONTACT PERSON:

Does your child suffer from any Medical Conditions?

Does your child experience any of the following during training/playing?

PLAYER MEDICAL FORM - CONFIDENTIAL