2022 Singa Cup – Medical and Health Information Form (Travelling Staff) "*" indicates required fields 1. Employee DetailsPlease enter the player’s details.Employee name* Given name Surname Gender*MaleFemaleNon-binaryAgenderMy gender isn't listedPrefer Not to AnswerDate of birth* DD slash MM slash YYYY 2. Emergency ContactPlease enter details of the person we should contact in the event of an emergency.Contact name* Given name Surname Relationship* Email address* Preferred contact number*3. Medical InformationPlease complete the medical information relating to the player nominated in section 1.Date of last tetanus vaccination* DD slash MM slash YYYY Do you suffer from any of the following?* Respiratory Problems Diabetes Headache/Migraines Skin Problems High Blood Pressure Epilepsy Eye/Ear problem Emotional Illness Asthma/Bronchitis Allergies (mild – severe) Digestive Disorder Other N/A Please specify*Are you required to take prescription medication during the tour?* Yes No Please specify*Do you have pre-existing injuries or illnesses that we should be aware of?* Yes No Please specify*Do you have any special dietary needs?* Yes No Please specify*4. Healthcare InformationPlease provide your Medicare and Private Health Insurance details.Medicare number* Do you have private health cover?* Yes No Does your policy include ambulance cover?* Yes No Private health fund* Member number* 5. Additional InformationPlease provide any further information you feel will be of assistance in the box below. 6. DeclarationsFootball West Touring Team Policy (Employees)* I agree to the Football West Touring Team Policy (Employees)Football West Touring Team Code of Conduct* I agree to the Football West Touring Team Code of ConductFootball West Chaperone Guidelines* I agree to the Football West Chaperone GuidelinesConsent* I hereby confirm that all information provided above is true and correct and give my consent for Football West to seek and authorise medical or other assistance as may be required.PhoneThis field is for validation purposes and should be left unchanged.