County Winter Sports Competition Parental Consent Form
Enter the member’s details, medical information, supervisor information, and emergency contact/consent information for the event.
Members details
First Name
*
Last Name
*
Club Name
*
Please Select
Please Select
Medical Information
Please provide details below
Doctors name
*
Area Code
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Is the named participant receiving any medical treatment or any prescribed medication?
*
Yes
No
Details of any medication to be taken, including frequency and any relevant side effects
Has the named participant ever suffered from any medical conditions (for example diabetes, asthma, migraine, epilepsy)?
*
Yes
No
Is the named participant allergic to anything (e.g. antibiotics, penicillin, elastoplast, asprin or any medicines, any particular foods etc)?
*
Yes
No
Supervisor details
If the parent/guardian is attending this event, please check YES below and proceed to Section 4.
First Name of Supervisor
*
Last Name of Supervisor
*
Is the named adult aware they have been nominated to supervise the member?
*
Yes
No
Email address of Supervisor
*
example@example.com
Name of club (if applicable)
Relationship to member
*
Area Code
*
Phone Number
*
Information and emergency contact details
Parent/Legal Guardian Name
*
First Name
Last Name
Emergency Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Consent and Acknowledgements
*
The medical information recorded on this form is correct to the best of my knowledge
In the event of illness or accident requiring hospital treatment, I understand that the responsible person at the event will make every effort to contact me
In an emergency, doctors or surgeons may make decisions regarding necessary treatment without my consent
I have read and understood the attached information and give my consent for my child to take part in this event
I am aware that the adults in charge will take all reasonable steps to protect participants from harm, but cannot necessarily be held responsible for any loss, damage, or injury suffered during or as a result of the activity
I confirm that I have parental responsibility or legal guardianship in relation to this member
Additional Emergency Instructions
Parent/Legal Guardian Signature
*
Submit
Submit
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