TTNZ Health and Contact Information Form

1. We ask that you complete the below form to the best of your ability. Your health, physical and emotional well-being are important to us.

2. All questions must be answered so that we can support your health needs whilst engaged in activities with Table Tennis New Zealand (TTNZ). If any point is unclear or you would like support in completing the form, please contact TTNZ.

3. Please give details of all medications, including traditional, homeopathic remedies and/or supplements.

4. Note that some medications may not be permitted under the rules of the sporting event and could result in you being disqualified from participating. Full disclosure at this point will help us manage your health and ability to partiicpate.

5. If you should become ill or have an injury close to, or on departure, please inform TTNZ as soon as possible so that we can manage your participation. It may be necessary to delay your departure or even decide that you may not be able to attend. Early advice will help us support you and reach a suitable arrangement.

Participant Name*

First NameLast Name

Participant Date of Birth*

Date

Role(s) or position(s) of a participant (Tick those that are appropriate)*

Participant Email*

example@example.com

Participant Phone Number*

Country CodeArea CodePhone Number

Participant Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/guardian Name of the player if under 18

First NameLast Name

Parent/guardian email(s) if the participant is under 18

example@example.com (AND) example2@example.com

Parent/guardian phone number of Player if under 18

Country CodeArea CodePhone Number

This section will collect key health information of the participant:

Please tick if you have any of the following*

Are you currently taking any medications?*

YesNo

Ailment(s):

Name of medication(s):

If you require support taking or managing medications please also state this.

Please advise if you believe for any reason you may need a Therapeutic Use Exemption (TUE). E.g., inhaler use, certain drug use for medical conditions*

YesNoUnsure

Have you had any major injuries (fractures or strains), concussion or illness (glandular fever etc) in the last 12 months that may impact on your participation?*

YesNo

If yes, please state the injury(ies) or illness(es):

Are you allergic to any of the following?*

If other, please state:

Do you require an Epipen?

YesNo

When was your last tetanus injection or booster?*

Emergency Contact Person*

First NameLast Name

Emergency Contact's phone number*

Country CodeArea CodePhone Number

Emergency Contact's Email*

example@example.com

Alternate Emergency Contact Name

First NameLast Name

Alternate Emergency Contact Number

Country CodeArea CodePhone Number

Is there any information that TTNZ should know to ensure your physical and emotional safety and well-being? For example, cultural practices, disability, anxiety about heights, darkness, small spaces, behaviour or emotional problems?*

If none, please write 'None'

Outline and special dietary requirements. For example, cultural practices, allergies, intolerances.*

If none, please write 'None'

Please advise any other matters that TTNZ should be aware of, that may impact your participation in any way: *

If none, please write 'None'

If emergency medical treatment for you/your child is required, whilst at an international activity do you approve for TTNZ and/or the international event organiser to arrange this at your cost?*

YesNo

Please upload a copy of you/your child's current passport *

Thank you for completing this form, to enable TTNZ to best support your health, physical and emotional well-being.