Medical Form

Pony Club Members attending Camps / Courses / Events

CONFIDENTIAL

This form is to be completed by the parent/guardian of our Pony Club Member:

Date of Camp / course or event / From
To
BRANCH
Name of Member
Date of Birth
Name(s) of Parent(s) / Guardian
Telephone Number(s)
Email Address
Address of Parent(s) / Guardian
Another authorised contact in case of emergency:
Telephone Number(s)
Member’s GP Name
GP Address
GP Telephone Number
Member’s Dentist Name
Dentist Address
Dentist Telephone Number

Does our Member suffer from (please tick any relevant condition) :

Asthma
Migraine
Dyslexia
Heart / Lung Disorder
Vision / Hearing Impairment
Gynaecological Disorders
Gastro-intestinal Disorders
Epilepsy
Fainting
Diabetes
Hay Fever
Bone / Joint Impairment
Ear / Nose / Throat complaints
Skin complaints
Allergy to drugs / food (please be specific)
Other (please be specific)
Does our member wear contact lenses

Religion if applicable to medical treatment or other considerations (please be specific)

Any other notifications that the welfare officer should be made aware of?

Does he/she regularly take any form of medicine? (please list medication & dose including intervals that it should be taken)

Are there any current injuries/recent operations/medical interventions that we should be aware of?

Any previous operations (eg appendix) please list-

Date of last tetanus injection

Has he/she ever had an adverse/allergic reaction to anything? (please list any allergies)

Has he/she any special dietary requirements?

Blood group (if known)

Any other special requirements?

In the event of my daughter/son requiring emergency medical or dental treatment whilst taking part in any pony club activity where I cannot be contacted by a responsible adult, I herby authorise the District Commissioner or other designated officer of the Pony Club to obtain such medical or dental treatment for my child, as they, in their absolute discretion, think necessary after consultation with a medical or dental practitioner. This authority extends to all medical and dental treatment including the giving of an anaesthetic where necessary.

Signed Parent/Guardian Date

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