EAST BERKS FOOTBALL LEAGUE

PARENT / GUARDIAN
CONSENT FORM

Details:	To cover all aspects of football for		Football Club	
					
From:	1st  August 2019 to 30th  June 2020				
				
I agree to		participating in the activities described.	
I acknowledge the need for		to behave responsibly.	
				
Medical Information about your son:				
			
A: Any conditions requiring medical treatment, including medication?		Yes  /  No	
				
If YES, please state details:				

B: Please outline any special dietary requirements of your son and the type of pain / flu relief medication your son may be given if necessary:

C: Is your son allergic to any medication?	Yes  /  No	
		
If YES, please specify:

D: When did your son last have a tetanus injection?

Declaration:

I will inform Football Club as soon as possible of any changes in the medical or other circumstances relating to my son.

I agree to my son receiving medication as instructed and any emergency dental, medical or surgical treatment including anaesthetic or blood transfusion, as considered necessary by the medical authorities present.

Contact Numbers:	Home:	Work:	Mobile:	
					
Home Address:					
				
Name of Family Doctor:				
					
Address:					
					
Signed:				Date:	
					
Full Name:				Parent / Guardian	
					
This form is to be taken to all matches the player is selected to play in