Medical Form | UndyAFC

Undy AFC Medical Declaration

All registered players should complete the following medical declaration.

This form can also be downloaded so that you can complete and hand to your coach here.

Player Details

Player Full Name

Date of Birth

Address Including Post Code

Home Tel No

Mobile Tel No

Emergency Contacts

First Contact Name

Relationship

Home Tel No

Mobile Tel No

Second Contact Name

Relationship 2

Home Tel No 2

Mobile Tel No 2

Medical Details

GP Name

Medical Practice

GP Telephone Number

Details of any known special dietary requirement/allergy/disability/medical condition or type none

Please provide a brief description of the effects of your disability or medical condition and any particular needs you may have or type none

Any other special needs, requirements, or directions that would be helpful for the coaches to know about or type none

Your Name

Date

Note: It is the responsibility of the parent/guardian to notify the club of any changes to this declaration and by signing this form you give consent for the appointed first aider to administer basic first aid or to take whatever action deemed appropriate in an emergency situation. If consent isn't given the parent/guardian must remain at the session at all times. This form will be retained by the team coaches for reference.

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