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Parklands Netball Club Inc.c/- Darebin YMCA
857 Plenty Road, Reservoir [email protected]
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 ice Yes / No Permission to lift player from court Yes / No
Permission to apply bandaids Yes / No Permission to apply tape Yes / 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: _____/______/______
Medical Form2019
