Australian Flying Disc Association Inc

AUSTRALIAN UNDER-22 ULTIMATE CHAMPIONSHIPS

Junior Participant Medical Details and Consent Form

Personal Details of Participant

Surname:
Given Names:
Date of Birth: / Gender:
Address:
Suburb: / State: / Postcode:
Phone (home): / Mobile:
Email:

Parent/ Guardian details

(Participation will not be allowed without the full details including email address of at least one parent, guardian or other emergency contact – this information will be kept confidential)

Contact 1:

Surname:
Given Names:
Phone (home): / Mobile:
Email:
Relationship to Participant:

Contact 2:

Surname:
Given Names:
Phone (home): / Mobile:
Email:
Relationship to Participant:

Team and responsible member details

(Participation will not be allowed without an AFDA approved member assuming responsibility for the participant for the duration of the event – this should be a team manager or coach)

Participant’s Team:
Responsible member:

Medical and Dietary Information:

Special/ Dietary needs

(Please identify any special needs or requirements eg. Diet – if any special requirements, please indicate suitable foods for group lunch/dinner)

Medical Information

Does the participant suffer from any of the following? Please tick all that apply.

/ Any allergic condition / / Skin condition / / Diabetes
/ Epilepsy, fits or blackouts / / Asthma / / Disability or chronic illness
/ Attention deficit disorder / / Sleep walking / / Other

(If yes to one or more, please provide details – attach sheet if required)

Please list all medications (including over the counter medications/dietary supplements) taken by the participant on a regular basis

Medicare no: / Position on card / Expiry:
Health care card no: / Ambulance cover? / Y/N
Private health fund: / Membership no:

Has participant had:

Combined Diptheria Tetanus Toxiod booster injection? / Y/N / Year:
Immunisation against measles? / Y/N / Year:

Swimming ability:

Can the participant swim 50 metres unaided?

Privacy statement: The AFDA will collect and store the information that you provide. It will be disclosed to the Australian Mixed Ultimate Championshipsorganisers, where necessary and you consent to this disclosure. Any information collected will be stored on a database and will only be accessed by authorised personnel and is subject to privacy restrictions. The information will only be used for the purpose for which it was collected which includes to assist in making decisions regarding medical treatment and to allow contact to be made in an emergency.

Statements of consent and waiver:

I understand that Ultimate is a physical and demanding sport that involves occasional body and ground contact, and as such injury is possible even in the most controlled conditions. Although the Australian Flying Disc Association (AFDA) and its representatives attempt to minimise any risk of personal injury, accidents do happen and all physical activities carry the risk of personal injury.

In the case of an emergency, I authorise the AFDA or its representative, where it is impracticable to communicate with me, to arrange for me to receive such medical or surgical treatment as may be considered necessary. I undertake to pay or reimburse any costs incurred for medical attention, ambulance transport and medication while I am a participant in the Australian Mixed Ultimate Championshipsto the extent that such costs are not covered by Medicare.

I undertake to abide by the AFDA’s policies, as displayed on and updated from time to time in relation to the behaviour of athletes including among others any Membership Agreement, Member Protection Policy and Anti-Doping Policy. I undertake to reimburse the AFDA for the full additional costs if I am sent home for disciplinary reasons.

Signature of participant (all participants to sign regardless of age):______

Parental Consent

I agree to my child’s/ ward’s participation in the Australian under-22 Ultimate Championshipsand make each of the above statements on their behalf.

Signature of parent/guardian:

______Print name: ______

Date: ___/ ___/ 2015Relationship to participant: ______

Media consent(to be completed by parent/guardian where the participant is less than 18 at date of signing):

I agree to allow the AFDA to use my / my child’s / my ward’s name and any photographs, sound and film recordings taken of me / my child / my ward at theAustralian Under-22 Ultimate Championshipsor the promotion of the AFDA and the sport of Ultimate to the media and to the general public.

Signature: ______

Relationship to participant (if under 18): ______Date: ___/ ___/ 2017

This form MUST be completed and returned to the junior participant’s State Team Manager.

Recognised by the Australian Sports Commission