GACT 2025 State Team - Medical Consent and Indemnity Form

Medical Consent & Indemnity

State Team 2025
State Team Members: Please complete one Medical Consent and Indemnity form per Team Member travelling to the Australian Gymnastics Championships with your nomination.
Club*
Full Name*

First NameLast Name
MAGWAGTRPACRO
GymnastOfficial
E-mail*
Phone*
Date of Birth*

DayMonthYear
MaleFemaleOther
I,*
Name
(Parent/Guardian – if under 18 years of age) hereby give permission for the Team Manager or coach, to seek medical aid in the event of an accident, injury or illness. General medical aid, including transport, will be at the discretion of the Manager or designated representative.

In addition:

Specific permission, on appropriate medical advice is given for the following:
YesNo
YesNo
YesNo
(General Note: Parents/Guardians will be contacted, if possible, prior to any medical attention being given.)
Medication
YesNo
If Yes, please list
Are there any relevant mental health issues to be aware of?
YesNo
Approx date of last concussion

DayMonthYear
Asthma
YesNo
YesNo
If yes, please provide details
Allergies
YesNo
If yes please list
YesNo
If yes please list
Do you carry an EPIPEN
If YES, for what allergy?
Health Insurance Information

Please complete where applicable
Medicare Number*
YesNo
Name of Fund
BasicIntermediateTop
Member Number
Emergency Contact Details

Team Members are requested to list at least 1 emergency contact
Contact Person 1*
Contact Number*
Relationship*
Contact Person 2
Contact Number
Relationship
I have read, understood, acknowledge and confirm that the information is true and correct
Full Name*

First NameLast Name
Should be Empty:

Medical Consent & Indemnity

Medication

Health Insurance Information

Emergency Contact Details