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1. My son/daughter has had the following immunisations: Triple Antigen Yes/No Sabin Yes/No Measles/Mumps Yes/No Hepatitis Yes/No 2. Date of last anti-tetanus injection: ___________________________________ 3. My son/daughter is known to be allergic to: ________________________________________________ 4. My son/daughter suffers from Asthma: Yes/No Medication available: ____________________________________________________________________ 5. My son/daughter is currently taking medication: Yes/No If so please give details: __________________________________________________________________ 6. Is you son/daughter suffering from an injury or condition which is likely to be aggravated by the competition?: Yes/No If so please give details: ______________________________________________________ _____________________________________________________________________________________ 7. Any relevant medical history: ___________________________________________________________ _____________________________________________________________________________________ 8. Medical Insurance Details: (a) Is your son/daughter issued with his/her own Medicare Card? Yes/No (b) If NO, please state Medicare Card holder’s name: (This is the first name on the card) _____________________________________________________________________________________ (c) State your son/daughter’s or family Medicare Membership Number: __________________________ (d) Detail any additional health benefits: eg. private hospital, ancillary, dental etc.: ____________________________________________________________________________________ (e) Additional Health Insurance Company and Membership number: ____________________________ (f) Are you a contributor to the QAS? Yes/No (g) Does your son/daughter have a Personal Accident Insurance cover against accident/injury for competitions and associated activities (training, travel, etc.)? Yes/No If so, detail the type of cover: ___________________________________________________________ ___________________________________________________________________________________ NOTE: It is the parents’ responsibility to ensure that the student is adequately covered by Medical Hospital, Dental and Personal Accident Insurance. Wide Bay School Sport cannot accept financial liability for any of these expenses. I hereby authorise the obtaining on my behalf of such medical assistance as my son/daughter may require in the event of an accident or illness and guarantee to meet any costs incurred. I authorise the administering of anaesthetic if this is deemed necessary by the medical officer attending. Signed: _________________________________ (Parent/Guardian) Date: ____________________ I hereby give consent for my son/daughter _____________________________ to participate in any competition arranged by or participated in by the Wide Bay School Sport Board or any affiliated body, and I hereby give my permission for him/her to use forms of transport, including air transport, for such travelling as may be deemed necessary. I also agree: 1. that during the period/s of the competitions in which my son/daughter participates, and during travel and other such activities as may be deemed necessary, my son/daughter shall be under the sole direction of the person/s duly appointed in charge of the team/s. 2. to pay the levy as set by the Wide Bay Primary/Secondary School Sport Management Committee and note that the levy must be paid at least one (1) week before departure. 3. to meet the costs for any illness, accident or unforeseen circumstances which may occur during the periods of the activities in which my son/daughter participates and during travel and other activities as may be deemed necessary. Signed: _________________________________ (Parent/Guardian) Date: ____________________ STUDENT PERSONAL DETAILS Player’s Name: ________________________________________________________________________ Date of Birth: __________________________ Home Phone/Contact: _____________________________ Home Address: ________________________________________________________________________ School Attended: _______________________________________________________________________ Father’s Name: _____________________________ Business Address: __________________________________________ Phone: ______________________ Mother’s Name: _____________________________ Business Address: __________________________________________ Phone: ______________________ Any Relevant Family History: ______________________________________________________________
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