Child Health and Medical Screening and Consent form
Under 18 years of age
Personal Details
Child's Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
If attending as part of a sporting club team training session - what club/team is the child a member of?
Parent/ Guardian Contact Details
Parent Full Name
*
Parent Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact details are the same as above?
*
Yes
No
Emergency contact - Relationship
Emergency Contact - Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Medical History
Does your child have any current or past medical conditions? (example: Asthma, seizures, diabetes)
*
Yes
No
Has your child experienced any of the below (Tick any that apply)
Blood pressure issues (high or low)
Chest pain, dizziness or fainting during exercise
History of joint or bone problems (arthritis, fractures etc)
Allergies (food, medical, environmental)
If you ticked yes to any of the above, please provide relevant detail below:
Does your child take any medication?
*
Yes
No
If yes, please list below:
Has your child been advised to avoid certain activities?
*
Yes
No
If yes, please detail below:
Consent and acknowledgement
Please tick
*
I confirm that I am the legal parent or guardian of the above-named child
I have disclosed all relevant information to the best of my knowledge
I authorise Dynamic Edge staff to seek emergency medical treatment if required.
I understand that participation in physical activity carries risk and consent to my child's participation
Parent/Guardian Signature
*
Parent /Guardian Name and electronic signature
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: