HockeyWA State Team Medical Information Form

Please note this information is strictly confidential and is to be used by HockeyWA staff and/or a representative of the team's off-field staff in the case of a medical emergency.

Player Personal Details

First Name*

Last Name*

Gender*

Date of birth*

Team*

Parent / Emergency Contact Details

First Name*

Last Name*

Address*

Mobile number*

Email*

Relationship*

Health Care Details

Doctor's name*

Phone number*

Dentist name*

Phone number*

Medicare number*

Expiry date*

Individual reference number*

Do you have private cover?*

Ambulance cover?*

Name of Private Health Fund*

Member number*

Medical Details

Has your child been vaccinated for COVID-19?*

Blood type*

Do you object to blood transfusion?*

Are there any medical conditions that we need to be aware of? E.g asthma, allergies, heart conditions, epilepsy.*

Is there any medication your child is currently taking? Please provide details including dosage.*

Please list any current or reoccurring injuries*

Has your child ever had a head, neck or spinal injury?*

Are your child's immunizations up to date?*

Do you give permission for your child to take Panadol or Nurofen if required?*

Final declaration

I acknowledge the information provided on this form is correct to the best of my knowledge*

Yes

Signed by*