• Medical Consent and Indemnity Form

  • Format: (000) 0000-0000.
  • Date of Birth*
     - -
  • What is your Gender?*

  • (Parent/Guardian – if under 18 years of age) hereby give permission for the Team Manager, or designated representative, 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:

  • General Anasthesia:*
  • Blood Transfusion:*
  • Traumatic injury requiring immediate surgery:*

  • (General Note: Parents/Guardians will be contacted, if possible, prior to any medical attention being given.)

  • Do you Object to Blood Transfusions*
  • Do you take regular medication?*
  • Have you been vaccinated against?
  • Have you ever had?
  • Have you ever had concussion?*
  • Approx date of last concussion
     - -
  • Have you ever had Head/Neck/Spinal injury?*
  • Have you had Fracture/Dislocation in last 3 years?*
  • Do you wear glasses?*
  • Do you wear contact lenses?*
  • What type of contacts do you use?
  • Do you suffer from asthma?*
  • Do you ever take medication for asthma?*
  • Do you bring your medication to training/competition?*
  • Are you allergic to?
  • Are you allergic to any types of food?*
  • Do you have any medication allergies?*

  • Health Insurance Information

    Please complete where applicable
  • Do you have Ambulance Cover?*
  • Do you have Private Health Insurance?*
  • Type of cover
  • Extra cover for Physiotherapy?
  • Coverage for overseas?

  • Emergency Contact Details

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Clear
  • Date Signed
     - -
  • Should be Empty:
Select theme:
  • Default
  • Blue
  • Red
  • Brown
  • Green
  • Black
  • Pink
  • Dark Blue
  • Purple