PARTICIPANT/PLAYER MEDICAL PROFILE � PERSONAL RECORD

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PARTICIPANT/PLAYER MEDICAL PROFILE � PERSONAL RECORD Powered By Docstoc
					                  TOOWOOMBA NETBALL SUPER CAMP ATHLETE
                  CONSENT & MEDICAL PROFILE PERSONAL RECORD
All information on this sheet is confidential. Access to this sheet is limited to medical staff and Toowoomba Netball Super Camp
 representatives. This information will be treated in accordance with the Toowoomba Netball Privacy Policy. The Toowoomba
              Netball Privacy Policy may be found on the organisation’s website at www.toowoomba.netball.asn.au


                                                Personal Details
Surname: _______________________ Given Names:________________________________

Address: ____________________________________________________________________

Suburb ______________________________________________                                       Postcode _____________

Phone (h) ________________ Mobile ____________________ Phone (b) ________________

Email _______________________________                                  Association _______________________

Sex:          M           F           Date of Birth: ____________________ Age: ________________

Dietary Requirements (e.g. vegetarian, celiac etc.): _______________________________

____________________________________________________________________________

                                             Emergency Contact
Surname:                                            Given Names:

Phone (h) ________________ Mobile ___________________ Phone (b) ________________

Relationship to above: ____________________________________


                                             Health Care Details
Medicare                   Private Health
Number ___________________ Insurance      Yes                                  No           Fund ________________


Private
Doctor: ______________________________________________ Phone _____________________

Address: ___________________________________________________________________________

Suburb ___________________________________________                                        Postcode ______________

Private
Dentist: _________________________________________ Phone _____________________

Address: ____________________________________________________________________

Suburb ___________________________________________                                        Postcode ______________
Certain medical conditions or previous injuries may influence your ability to participate in sport.
Examples of these include but are in no way limited to:
    Asthma
    Diabetes
    Epilepsy
    Spinal Injuries
    Arthritis
    Previous Injuries

If you have any pre-existing conditions or any concerns about participating, we would encourage
you to seek medical clearance from your doctor prior to participating in sport.

Do you have any allergies or phobias? ……………………………………………………………..

Do you have any conditions that you, in consultation with your doctor, consider appropriate to
notify the Toowoomba Netball Super Camp representatives of?

If so, please provide details here:
…………………………..……………………………………………………………………………………
………………………………………………………………..………………………………………………
………………………………………………………………………………………………………………..

As Parent/Guardian with legal responsibility for the participant      _____________________________
                                                                                    (Child’s full name)
I, ______________________________ give my permission for him/her to participate in the Netball Clinic/Camp as
            (Parent/Guardian full name)
detailed in the flyer. I am aware of the nature of the activities and agree to delegate my authority to the staff and
instructors involved. I accept that the staff and instructors will take appropriate disciplinary action necessary to ensure
the safety, well being and successful conduct of the group who participate in the activities associated with the
clinic/camp.

In the event of illness or accident, I authorise the obtaining of such medical assistance as my child may require. I
accept all medical treatment, blood transfusions and/or anaesthetic risks involved and the responsibility for payment
of any expenses this incurred.

I forward the complete medical information section about my child to assist those who are organising the Camp/Clinic.

I understand and accept travel arrangement detailed and consent for my child to travel as detailed.



To the best of my knowledge, all information contained on this sheet is correct
       (if under 18 please have parent or legal guardian sign).


Signature                                                                                Date
(Participant)



Signature                                                                                 Date
(Parent or Guardian




  DISCLAIMER
  "The information contained in this resource is in the nature of general comment only, and neither purports, nor is intended, to be
  advice on a particular matter. No reader should act on the basis of anything contained in this resource without seeking
  independent professional advice from appropriate persons. No responsibility or liability whatsoever can be accepted by
  Toowoomba Netball or the authors for any loss, damage or injury that may arise from any person acting on a any statement or
  information contained in this resource and all such liabilities are expressly disclaimed."

				
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posted:10/3/2012
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