Netball Sample Form - Indemnity And Consent Form printable pdf download

Netball Sample Form - Indemnity And Consent Form

Sample Form - Indemnity and Consent Form

PERSONAL AND MEDICAL INFORMATION

I hereby consent to the provision of the following health information for _______________________ Netball

Association/Club records and to use in the event of injury, illness or emergency, if required.

Your details will be disclosed to the _______________________Netball Association/Club committee and other

relevant personnel such as coaches, team managers and primary care staff.

Name:

Address:

Postcode:

Phone No (home):

Date Of Birth:

Medicare No.

Ambulance Member No.:

Private Health Insurance Provider:

Existing Medical Conditions/Injuries/Allergies:

Regular Medication:

Next Of Kin (1):

Daytime Phone No:

After hours Ph No:

Next Of Kin (2):

Daytime Phone No:

After hours Ph No:

CONSENT: I understand that the game will be played under the rules as set by Netball Australia. I also understand

that netball is a limited contact sport and that there is a risk of injury involved in participating in netball. I

authorise any official from the Club/Association in the event of any injury or illness, to obtain on my behalf and at

my expense any medical assistance, treatment and transportation as deemed necessary.

INDEMNITY: Except where provided or required by law and such cannot be excluded, I agree that Club/Association

and its respective directors, officers, members, servants or agents are absolved from all liability however arising

from injury or damage to me, however caused, arising whilst participating in the game. I have read, understood

and agree to the above terms. I warrant that all information provided is true and correct.

Signed :

Date:

I have read, understood and agree to the above terms and I personally consent to the application of my child. I

warrant that all information provided is true and correct.

Signed (parent/legal guardian):

Date:

Netball Sample Form - Indemnity And Consent Form