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.