2023 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 2023 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. EmailThis field is for validation purposes and should be left unchanged.