Medical Consent form Medical Consent Form Ballarat Swim Club Medical Consent Form Please complete one form for each person swimming with the Ballarat Swimming Club. Information provided will only be used in the event your child should need treatment and would be passed onto Medical Personnel by Coaches. Consent* I consent my son / daughter participating in Ballarat Swimming Club’s swimming program and cross training as authorized by the coaches.Swimmers Name* First Last Date of Birth* DD slash MM slash YYYY Medicare Number*Please include family number on card. For e.g 123456789/1 Medicare Expiry*00/0000 Ambulance Number* Does your Child Suffer from travel sickness* Does your have any allergies?* Please list any existing medical conditions or illnesses*including asthma, diabetes, epilepsy Briefly outline any treatment/medications for each including dose and frequency Does Your child carry any medication with them?* Does Your child know how to use their medication? Family Physician Name* First Last Family Physician Phone*Emergency Contact 1* First Last Phone*Emergency Contact 2.* First Last Phone*Emergency Contact 3. First Last PhoneMedical Consent* I agreeIn the event of my child requiring medical treatment or in case of a medical emergency, I consent to the Ballarat Swimming Club Inc. and its representatives, providing first aid or treatment and I further authorise the Ballarat Swimming Club and its representatives, where it is impracticable to communicate with me, to arrange for him/her to received such medical and/or surgical treatment as may be deemed necessary. I also undertake to pay any and all costs which may be incurred for the first aid, medical treatment, ambulance transport and drugs. I would expect a Ballarat Swimming Club representative to contact me as soon as possible. Name*Name of parent/Guardian completing the Medical consent Form First Last Date* DD slash MM slash YYYY
