Swindon Town FC Academy - Medical and Photo Consent Form 20/21

Please read this form thoroughly and complete it accurately. If there are ANY changes to the medical form once completed, please ensure you advise the club ASAP.

If you have any questions regarding this form, please let us know.

Name of Player: *
Age Group: *
Players Date of Birth: *
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FULL Address: *
Postcode: *
Doctors Name and Surgery Name (if you are not registered with a doctor, please state on this form) *
Emergency Contact Name and Relationship to Player: *
Emergency Contact Telephone Number (please state WORK, HOME or MOBILE): *
Does your child suffer from any of the below? *
Required
If your child has any of the above, please give details:
Are there any other medical conditions that staff/coaches need to be aware of, which may require medical treatment? *
If YES, please give details:
Has the player needed any physiotherapy treatment in the past? *
If YES, please give details:
Does the player have any allergies? *
If YES, what is the player allergic to and what reaction develops?
Does the player carry, or use an epi-pen? *
To the best of your knowledge, has the player been in contact with any contagious or infectious diseases, or suffered from anything within the last 4 weeks, that may be contagious or infectious? *
If YES, please give details:
Is there any other medical information you can provide, or concerns you have in relation to the players health during the 2019/20 season? *
If YES, please give details:
Do you consent to your sons photograph/name being used in any publication regarding fixtures, tournaments or trips? *
Declaration: I agree to my son receiving medication as instructed. I give consent for Swindon Town FC Academy staff to ensure that my son receives the necessary medical attention where needed. (Please state your name/initials) *
Declaration: I have read and fully understand this form. I have answered questions thoroughly and accurately. I understand that it is my responsibility to inform the medical team/coaches of any changes to the medical form. (Please state your name/initials) *
Please state the date that you completed this form: *
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