NBGA Medical Consent Form

Northern Beaches Gymnastics Academy
Medical Consent Form
Name*

First NameLast Name
On Date*

MonthDayYear
Date
Address*
Post Code*
Email*
example@example.com
DOB*
Age*
Mobile/Contact No*
I, (parent if under 18 years of age) blanks* hereby give permission for the program manager, or designated staff representative, to seek medical aid in the event of an accident, injury, or illness to the above participant.

General medical aid, including transport, will be at the discretion of the program manager, or designated staff representative.

In addition:
Specific permission, on appropriate medical advice, is given the following:
Does your child have any behavioural/ learning difficulties that we should be aware of: Yes No*
If Yes, please state:
Type a label*
Has your child had an injury/ illness in the past 12 months*
Details if yes*
Has your child been cleared to participate in an active program*
Does your child suffer from any condition that could involve hospitalisation (eg: asthma) Yes 1 No
If Yes, please state: Type a label
Known Allergies YES / NO *
If YES, please state*
Medication required (please include dosage):
Name of Medication*
Dosage*
(N.B. Medication can only be administered if dosage is clearly labelled by Dr and Pharmacy Pack)
Medicare Number
I/We have additional Hospital /Medical cover Yes / No
I/We have additional hospital/ Medical cover Yes No
Name of Fund
Membership Number
I have supplied all information as the legal Parent/Guardian of the child's name in this form and I declare the information to be true and correct as stated:
Signature*

Clear
Full name of Parent/ Guardian*

First NameLast Name
Supervisor Signature

Clear
Name
Should be Empty:

Northern Beaches Gymnastics Academy

Medical Consent Form