2024 NW John Holland NW Championships – Medical, Health & Media Consent Form "*" indicates required fields 1. Player DetailsPlease enter the player’s details.Player name* Given name Surname Gender*MaleFemaleNon-binaryAgenderMy gender isn't listedPrefer Not to AnswerDate of birth* DD slash MM slash YYYY Association*— SELECT —BroomeHedlandKarrathaNewmanTom Price2. 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 Does the player 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*Will the player require medication during the tournament?* Yes No Please specify*Does the player have any pre-existing injuries?* Yes No Please specify*Does the player 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. DeclarationsMedia consent*I grant Football West to take photographs/videos of my child at the 2024 North West Championships. I grant Football West full rights to use the images resulting from the photography/video filming. This may include (but is not limited to), the right to use them in their printed and online publicity, social media and press releases. I agree for my childs photo to be taken and used as outlined above. I do not agree for my childs photo to be taken or used. Please note, if you do not wish for your child’s photo to be taken, you must come to the Football West tent to receive a wristband. CommentsThis field is for validation purposes and should be left unchanged.