JUNIOR MEDICAL

Name of junior player*
Date of birth*
Name of primary contact*
First Last
Email of primary contact*
Address*
Street Address Address Line 2 City Postcode
Primary contact's relationship to player*
- Parent
- Grandparent
- Sibling
Phone number of primary contact*
Name of secondary contact*
First Last
Email of secondary contact*
Secondary contact's relationship to player*
- Parent
- Grandparent
- Sibling
Phone number of secondary contact*
Would you like the secondary contact to be included in non emergency email communications?*
- Yes
- No
Does the player have any specific medical conditions, long term injuries or disabilities?*
Please give any details or medication required. If none put N/A
Any allergies or dietary requirements*
Please give any details or if none put N/A
I understand that in the event of any injury or illness, all reasonable steps will be taken to contact me and to deal with that injury/illness appropriately*
- Yes
The information in this form will be securely stored and can be accessed by EBA coaches who might pass onto relevant medical staff.
Would you like to add a third contact?*
- Yes
- No
Name of third contact*
First Last
Email of third contact
Third contact's relationship to player*
- Parent
- Grandparent
- Sibling
Phone number of third contact*
Would you like the third contact to be included in non emergency email communications?*
- Yes
- No