Medical Form Step 1 of 2 - Form50%Personal DetailsPlayer Name* First Last Player/Parent/Guardian Email* Team for this year:*Team last year (if not MEJFC):Gender*MaleFemaleAddress* Street Address Address Line 2 City State Postcode Player Home Phone*Player Mobile Phone (if applicable)Parent / GuardianParent / Guardian Name* First Last Parent / Guardian Phone*Medical DetailsAmbulance Membership*YesNoAmbulance Number*Medicare Number*Private Health*YesNoAre immunisations up to date?*YesNoDate of Tetanus Injection DD MM YYYYDoes your child suffer from: Asthma Tape Allergy Heart Disease Epilepsy Diabetes Blood Disorders Kidney Disease Lung Disease Other (Please Detail) Any Medications? (Please Detail)Details or Asthma plan*Details or other info re Tape AllergyDetails or other info re Heart DiseaseDetails or other info re EpilepsyDetails or other info re DiabetesDetails or other info re Blood DisordersDetails or other info re Kidney DiseaseDetails or other info re Lung DiseaseDetails or other info re OtherDetails or other info re MedicationsConcussionHas your child suffered from concussion?*YesNoHow many times?*Did they lose consciousness?*YesNoWere they hospitalised?*YesNoAny other details?MediaDo you approve the use of your child’s photo on our club media sites?*YesNoDECLARE* I/We acknowledge that:If any information changes during the season, we are required to inform the club immediatelyThe club insurance does not cover ambulance costs. If you do not have an ambulance subscription, you will be liable for any costs incurredThese records are confidential and only used for registration, medical and sports training staffI authorise the Mount Evelyn Junior Football Club Inc to consent, where it is impracticable to contact me, to my child receiving such medical treatment as may be deemed necessaryI declare that the above information is, to the best of my knowledge, true and correct and that my child and I agree to abide by the MEJFC Player and Parent HandbookSigned by*Date: 18/10/2021Signature*Unique ID{all_fields:noadmin}
