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Medical Information
Medical Information Form for 21/22.
Please note, you will need to make the Manager/Coach aware of any medical conditions.
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* Indicates required question
Surname
*
Your answer
Forename(s)
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Please indicate if you have any medical conditions we should be aware of.
*
Yes
No
If you do have any medical conditions, please supply details. e.g. asthma
Your answer
Emergency Contact
Surname
*
Your answer
Forename(s)
*
Your answer
Relationship to above-named player
*
Your answer
Emergency telephone number
*
Your answer
Medical Consent
In the event that my son/daughter is injured whilst playing football/travelling to and from football events and I cannot be contacted on the above number, I hereby give consent for my child to receive medical attention
Name
*
Your answer
I agree to the Medical Consent paragraph outlined above
*
Signed
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