Skip to content

About
Teams
- Registration
News
Shop
Events
Contact

Facebook Google-maps Instagram

Log In

About
Teams
- Registration
News
Shop
Events
Contact

Player Medical Form

Home Player Medical Form

Medical Form

"*" indicates required fields

Step 1 of 2 - Form

50%

Personal Details

Player Name*

First Last

Player/Parent/Guardian Email*

Team for this year (2022):*

Team last year 2021-(if not MEJFC):

Gender*

Male

Female

Address*

Street Address Address Line 2 City State Postcode

Player Home Phone*

Player Mobile Phone (if applicable)

Parent / Guardian

Parent / Guardian Name*

First Last

Parent / Guardian Phone*

Medical Details

Ambulance Membership*

Yes

No

Ambulance Number*

Private Health*

Yes

No

Medicare Number*

Are immunisations up to date?*

Yes

No

Date of Tetanus Injection

Day

Month

Year

Does 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 Allergy

Details or other info re Heart Disease

Details or other info re Epilepsy

Details or other info re Diabetes

Details or other info re Blood Disorders

Details or other info re Kidney Disease

Details or other info re Lung Disease

Details or other info re Other

Details or other info re Medications

Concussion

Has your child suffered from concussion?*

Yes

No

How many times?*

Did they lose consciousness?*

Yes

No

Were they hospitalised?*

Yes

No

Any other details?

Media

Do you approve the use of your child’s photo on our club media sites?*

Yes

No

DECLARE*

I/We acknowledge that:

If any information changes during the season, we are required to inform the club immediately
The club insurance does not cover ambulance costs. If you do not have an ambulance subscription, you will be liable for any costs incurred
These records are confidential and only used for registration, medical and sports training staff
I 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 necessary
I 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 Handbook

Signed by*

Date: 19/05/2022

Signature*

Unique ID

{all_fields:noadmin}

Our Sponsors

Thank you to our wonderful Sponsors for your continued support

Mt Evelyn Garden Centre

KELM

Tram Xpresso

Stroud Homes

Jk1-1

JK&S Builders

Club Newsletter

Sign up to our newsletter to receive club news and event updates.

Name
First
Email*

News
Shop
Events
Contact Us
Home of the Rovers

Log In / Account
Cart
Terms and Conditions
Privacy Policy
Sitemap

Play_AFL_A

NAB_AFL_Auskick_A

AFL-Vic-Outer-East

AFL-Victoria-Colour

aflw-corporate

AFL_Corporate_A

© Mount Evelyn Junior Football Club • 2022 • ABN: 43921993496

×

wildeye green hosting

wildeye web design

Scroll To Top