Microsoft Word - PNC_registration2009.rtf

( Medical Form2019)

Parklands Netball Club Inc.

c/- Darebin YMCA

857 Plenty Road, Reservoir 3073

president@parklandsnetballclub.org

www.parklandsnetballclub.org

Please return form with registration forms

Player Name:____________________________________________________Date of Birth:_______________________

Address: _________________________________________________________________________________________________________

Suburb: _______________________________________________________________________ Postcode: ________________________

Parents/Guardian 1 Name: ___________________________________________ Mobile: _________________________________

Parents/Guardian 2 Name: ___________________________________________ Mobile: _____________________

Emergency Contact (if not Parent /Guardian 1 or 2)

Name:_____________________________________ Relationship: __________________________Phone:______________________

Ambulance Subscriber: Yes / No Member No: _____________________________________

Medicare Number: _________________________________Expiry date:

Medical History & Treatment Consent

Does your child have any medical condition which may require our attention during matches or training?

If so please advise: _____________________________________________________________________________________________________

_____________________________________________________________________________________________________________________

If a problem arises relating to this condition what action should be taken? ______________________________________________

_________________________________________________________________________________________________________

Do we have:

Permission to apply iceYes / NoPermission to lift player from court Yes / No

Permission to apply bandaidsYes / NoPermission to apply tapeYes / No

I ____________________________________________ parent/guardian give permission for my child to be given such medical treatment as may be deemed necessary in my absence,

Signed: _________________________________________________ Parent / Guardian Date: _____/______/______