Nottingham Athletic-Basketball form

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For Parent/Guardians

Full Name *

Child's Name *

Date of Birth of Child E.g (17/05/2009) *

YYYY

Relationship to child *

Email *

Address *

Post Code *

Phone number *

Second contact name

Second contact number

Does your child have medical conditions *

Yes

If there are medical conditions, please specify

Is your child taking medication? *

Yes

Has your doctor ever advised your child not to exercise? *

Yes

Do your consider the child to have a disability/disabilities? *

Yes

`No

If yes please specify by ticking a box

Hearing impairment

Visual impairment

Mental health issues

Physical disability

Learning disability

Do not wish to disclose

Other:

Clear selection

Medical/Health Information - Does the child have or have they ever experienced the following *

High or low blood pressure

Diabetes

Childhood epilepsy

Bone, joint, or muscular problems with arthritis

Any sustained injuries or illness

Elevated blood cholesterol

Chest pains brought on by physical exertion

Dizziness or fainting

Asthma or respiratory problems

Allergies

None

Required

Please add further details here

Any individual needs that we may need to be aware of when supporting your child in session

Tick what you are able to consent to *

I consent for my child to take part in basketball

I can confirm I have read or been made aware of the photo and video guidance policy

I can confirm I have been made aware of how photos and videos are used within the club, and how they are stored

I consent for my childs picture/video to be taken and used for the clubs social media and player development

I understand consent lasts for one whole year, unless stated otherwise and that if I wish to remove my consent, I must contact any member of staff at Nottingham Athletic

I confirm to the best of my knowledge that the information I have provided is correct and will advise the club of any changes to this information

I consent for my child to receive emergency medical treatment or first aid by a qualified medical practitioner or first aider if considered necessary

Required

Submit

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