Accrington Stanley Academy: Player Medical Information & Medical Consent Form
Please complete to help us create a database of player medical information. All data will be stored safely and according to the club's GDPR policy, and will only be accessible to relevant full-time members of staff. This database is deemed essential for enhanced club communication, is for our internal use only, and will not be shared with any external parties.

Failure to declare previous medical illness or injury that could impact on a player’s performance and development may result in termination of registration at the Academy. The assessment and treatment you receive via the medical team at Accrington Stanley Academy should always be done in conjunction with standard NHS or private healthcare. Any questions or queries during the rehab process please direct to an appropriate member of staff.
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Player Name: *
Player Age-Group: *
Player Date of Birth: *
MM
/
DD
/
YYYY
Doctor's Name:
Local Surgery/Practice (including postcode):
Does your child suffer from any of the following symptoms? *
Required
Does your child currently take any regular medication? *
If yes, please state below:
Is your child currently allergic to any medication? *
If yes, please state below:
Does your child suffer from any other medical condition not previously stated? *
If yes, please state below:
Has your child ever been knocked unconscious or suffered from concussion? *
If yes, please state below:
Does your child suffer from any heart conditions, such as congenital defects or arrhythmias? *
If yes, please state below:
Has your child ever fainted or felt dizzy during or following exercise? *
If yes, please state below:
Has your child ever experienced chest pain, and heaviness or tightness during or following exercise? *
If yes, please state below:
Does your child have a family history of any of the following: heart disease, high blood pressure, high cholesterol, diabetes? *
If yes, please state below:
Do you consent to your child receiving necessary first aid treatment; medical testing and screening; and any treatment deemed necessary for the rehabilitation of any injury sustained whilst training or playing with Accrington Stanley Football Club? *
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