Medical Consent Form
For NSSA and Impulse Training Events
Name of Trainee
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Country Code
-
Area Code
Phone Number
Start Date of event
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Emergency Contact
*
Phone Number for Emergency Contact
*
-
Country Code
-
Area Code
Phone Number
I set out below (or on an attached note) details of any medical condition from which I/my child is suffering, together with details of the treatment required and medication currently being taken or carried,
*
Dietary Requirements
*
I authorise NSSA/Impulse staff on the Camp or training day, if necessary, to give consent on my behalf for an anaesthetic to be administered or for any other urgent medical treatment to be given to or surgery to be carried out on me/my child on the advice of a qualified medical practitioner.
*
Yes
No
Submit
Should be Empty: