GHPC Medical & Emergency Information Form 2027

GHPC Medical & Emergency Information Form 2027

The safety and wellbeing of our members is important to us. Please complete this form with current and accurate information so GHPC has the information we need to support you or your child during GHPC classes, competitions, events and other club activities. Please complete one form for each member. If any of the information provided changes during the year, please let us know so we can keep our records up to date.
MEMBER DETAILS
Member's Full Name

First NameLast Name
Birth Date

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Is this form being completed for:
Parent/Guardian Name (only required if completing for a child)

First NameLast Name
Parent/Guardian Phone Number (only required if completing for a child)

Area CodePhone Number
EMERGENCY CONTACT 1
Emergency Contact Full Name

First NameLast Name
Relationship to member
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Mobile

Area CodePhone Number
Home phone

Area CodePhone Number
Work phone

Area CodePhone Number
Is this person authorised to collect the member if required?
EMERGENCY CONTACT 2
Emergency Contact Full Name

First NameLast Name
Relationship to member
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile

Area CodePhone Number
Home phone

Area CodePhone Number
Work phone

Area CodePhone Number
Is this person authorised to collect the member if required?
MEDICAL INFORMATION
Does the member have any medical conditions, health concerns or injuries that GHPC should be aware of?
If yes, please provide details:
Examples may include asthma, diabetes, epilepsy, heart conditions, recent injuries, ongoing conditions or anything that may affect participation.
Does the member require any medication during GHPC activities?
If yes, please provide details, including the medication and when/how it may be required
ALLERGIES / ASTHMA / MEDICATION
Does the member have any allergies?
If yes, please list the allergy and describe any known reaction or required response:
Does the member have an allergy that could result in an anaphylactic reaction?
If yes, does the member have an ASCIA Action Plan or other medical management plan?
If yes, please provide details:
If there is a ASCIA Action Plan or other medical management plan, please email this to gilliestonheightsphysie@gmail.com
If yes, does the member have an adrenaline auto-injector (e.g. EpiPen)?
For members under 18:

The member's allergy medication and adrenaline auto-injector (e.g. EpiPen) must be provided to the teacher before classes and workshops or kept with the parent/guardian when they are present and supervising.
For members 18 and older: Where will you keep your allergy medication and adrenaline auto-injector (e.g. EpiPen) during GHPC activities?
Does the member have an asthma action plan?
Does the member have asthma or require reliever medication?
If yes, please provide details of the medication and relevant instructions for use.
If there is a asthma action plan, please email this to gilliestonheightsphysie@gmail.com
For members under 18:

The member's reliever medication must be provided to the teacher before classes and workshops or kept with the parent/guardian when they are present and supervising.
For members 18 and older: Where will you keep your reliever medication during GHPC activities?
INJURIES & PARTICIPATION
Does the member currently have an injury, condition or physical limitation that may affect participation in Physie?
If yes, please provide details and any relevant restrictions or recommendations:
Are there any activities or movements the member should avoid or modify?
If yes, please provide details:
Please provide details of any medical conditions, previous injuries or other health considerations that GHPC should be aware of.
Are there any other medical, health, physical, wellbeing or participation considerations that GHPC should be aware of to safely support the member?
If yes, please provide details:
Declaration

I confirm that the information provided is accurate and that I have authority to provide the information for the member named above.
Name

First NameLast Name
Signature
Date:
Should be Empty:

GHPC Medical & Emergency Information Form 2027

MEMBER DETAILS

EMERGENCY CONTACT 1

EMERGENCY CONTACT 2

MEDICAL INFORMATION

ALLERGIES / ASTHMA / MEDICATION

INJURIES & PARTICIPATION

Declaration