2026 Hockey WA State Health and Medical Form (Seniors)

This form is for state athletes 18 years and older.

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.

It is your responsibility to check all revelant relevant sites for banned/restricted substances. And to have the Sports Integrity APP on your mobile.

https://www.wada-ama.org/en/news/wada-publishes-2024-prohibited-list

Sports Integrity Australia APP

And if you require HWA to apply for TUE (Theraputic Use Exemption) you must do so well before departure of championship.

Please reach out to Performance & Pathways Lead Joanna Vaauli if you have any questions or concerns; joanna.vaauli@hockeywa.org.au

Athlete First Name*

Athlete Last Name*

Gender*

Date of Birth*

Team*

Emergency Contact Name*

Is the Emergency Contact Travelling to Championship?*

Emergency Contact Mobile Number*

Emergency Contact Email*

Emergency Contacts Relationship to Athlete*

Health Care Details

Doctor's Name*

Doctor's Phone Number*

Dentist Name*

Dentist 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

Blood type*

Do you object to blood transfusion?*

Are there any medical conditions that we need to be aware of (heart conditions, epilepsy, diabetes, asthma, allergies etc.)*

Please list all medication you are currently taking?*

Please list any current or reoccurring injuries*

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

Are your immunizations/tetanus up to date?*

Final declaration

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

Yes

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