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*
Date Format: MM slash DD 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
Phone
Medical Consent*
I agree
In 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

Medical Consent form

Medical Consent Form

BALLARAT SWIMMING CLUB

LOCATION

SOCIAL MEDIA

© Ballarat Swimming Club | Website by

Medical Consent form

Medical Consent Form

BALLARAT SWIMMING CLUB

LOCATION

SOCIAL MEDIA

© var d = new Date(); document.getElementById("copyright_year").innerHTML = d.getFullYear(); Ballarat Swimming Club | Website by

© Ballarat Swimming Club | Website by