Junior Medical and Registration Form.

Please complete this form and return it to Sue McIvor (Registrar - Juniors)
19B Melrose Street, Mordialloc, 3195.

Child's Name ................................................................. Date of Birth ...................................

Address .......................................................................................................................................

....................................................................................................... Postcode ..............................

School Attended ........................................................................................................................

Home Phone # ................................................ Business Phone # ........................................

Doctor's Name ................................................. Doctor's Phone # ........................................

Medical Condition

Further information or special instructions for emergency action
Epilepsy Yes/No *
Fainting/Dizzy Spells Yes/No
(other sudden loss of consciousness)		 *
Heart condition Yes/No *
Diabetes Yes/No *
Ear Disorder Yes/No
(particularly drainage tubes / deafness)		 *
Respiratory Disorder Yes/No
(particularly asthma)		 *
Allergies Yes/No
Particularly insect bites and stings		 *
Other relevant medical information. *

PLEASE READ, UNDERSTAND OR SEEK INDEPENDENT ADVICE IN REGARD TO THE FOLLOWING CONDITIONS, EXCLUSIONS OF LIABILITY AND INDEMNITIES BEFORE SIGNING THE MEDICAL REGISTRATION FORM. 

I request that you accept this application for my child / children to play hockey and to participate in hockey training, and in consideration of you doing so I agree that Moorabbin Districts Hockey Club and its officers, servants and agents are to be free and clear of all responsibility whatsoever, for any illness, accident or injury that may occur to my child / children during the participation in any activity or function associated with or connected thereto, and I do fully indemnify Moorabbin Districts Hockey Club and its offices, servants and agents against any damages, claims at law including negligence or other demands whatsoever in respect thereof.

 I do also agree that the Moorabbin Districts Hockey Club and its officers, servants and agents are to be free and clear of any responsibility whatsoever arising from any conduct or omission of conduct by my child / children during or associated with the above mentioned participation in any activity or function connected thereto, and I do fully indemnify Moorabbin Districts Hockey Club and its offices, servants and agents against any damages, claims at law including negligence or other demands whatsoever in respect thereof.

 I further authorise the Moorabbin Districts Hockey Club, its officers, servants and agents in the event of any such accident, illness or injury to my child / children to obtain all necessary assistance, ambulance or other transport, medical treatment and hospital accommodation for my child/ children in the event. I agree to pay all such expenses, fees and costs incurred in obtaining and providing such assistance, ambulance or other transport, medical treatment and hospital accommodation to my child / children in the event, and agree to indemnify the Moorabbin Districts Hockey Club its officers, servants and agents for all such expenses, fees or costs.

 I do also herewith authorise and provide formal permission for anaesthetic, blood or blood product transfusion or other medical procedure to be administered to my child / children by a person qualified at law to do so, and in circumstances where a person qualified at law to do so deems appropriate to provide such anaesthetic, blood or blood product transfusion or other medical procedure as a result of the foregoing illness, accident or injury.

Medicare # __ __ __ __ - __ __ __ __ __ - __

Mother's First Name ...................................... Father's First Name ...........................................

Parent's Signature .......................................................................... Date ............................................

 

Junior Registration Kit for Season 2003

 

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Moorabbin Districts Hockey Club Inc. 1997

Page created by: Gary Simmons, Moorabbin Districts Hockey Club
Last Updated: 18 April 2001