Form 25 Team Official Emergency Medical Information NAME:_________________________________ TEAM: _____________________________________ EMERGENCY CONTACT 1 Surname Relationship to Official Home Address Given Name Postcode Home Telephone Contact Email Business Address Mobile Telephone Business Telephone Mobile Telephone Postcode EMERGENCY CONTACT 2 Surname Relationship to Official Home Address Given Name Home Telephone Contact Email Business Address Mobile Telephone Business Telephone Mobile Telephone Postcode Postcode MEDICAL INFORMATION Immunisation Details (Please complete. List others as appropriate) Injection Yes No Tetanus Hepatitis B Do you get asthma? Is your asthma, Exercise induced asthma? If Yes to any of the above, list medication and attach Action Plan. Do you suffer from Anaphylactic reactions? If Yes list medication and attach Action Plan. Are you currently being treated by a medical practitioner? If Yes list details. NOTE: Please list any current medication. Medicare Card No. Date of Injection Yes Yes No No Yes No Yes No Position No. Cardholder Name Private Health Insurance Company Name (if covered) Private Health Insurance Membership Number Please list any other relevant medical history or additional support needs Please provide a copy to other team officials from your sport and email to [email protected] two weeks prior to the State Championships Metropolitan West School Sport, as an operational unit of the Department of Education and Training, is collecting the information on this form in accordance with the Information Privacy Act 2009 in order to share this medical history with medical professionals in the event of an accident or illness. The information will only be accessed by persons authorised by Metropolitan West School Sport, including appointed team officials. The information provided will not be used or disclosed to any other person or agency unless either you have given permission, it is required by law or in the interests of student health and welfare.
© Copyright 2024 Paperzz