SEPARATE FORM TO BE COMPLETED FOR ALL YOUTH SECTION PLAYERS
Player's Full Name:
Date Of Birth
Age Group Squad Please selectU6U7U8U9U10U11U12U13Girls U13U14U15Girls U15U16Girls U18Colts

IN CASE OF EMERGENCY PLEASE DESIGNATE TWO ADULTS

Parent/Guardian contact details:
Name:
Mobile No:
Name:
Mobile No:
PLEASE DISCLOSE ALL KNOWN CONDITIONS:
Does the player have any medical conditions (eg Asthma, Epilepsy)? YES
NO
Does the player have any known allergies (incl Penicillin?) YES
NO
Does the player have any additional needs? YES
NO
Has the player ever suffered any significant injuries*? YES
NO
Has the player undergone surgery? YES
NO
If Yes to any of the above, please give details, including dates where relevant (use separate sheet if needed):
CONCUSSION - Has the player ever suffered a concussion? If so, please give details of date, how caused and severity:
Has the player been vaccinated against Tetanus in last 5 years? YES
NO
MEDICATION being taken (includes inhalers etc.):
Other Relevant Information (which medical staff or first aiders should know):
Medical Declaration The information in this form will be retained by the Club’s medical team and will be made available to the age group management. I confirm that the information given is correct at the time of signing and authorise the Club to retain it and use it for the purpose of safeguarding my child’s welfare and to assist first aiders and medical staff.
I shall inform the Club immediately if: (a) there are any changes to my child’s health or to any of the above information; (b) the player suffers any injuries or develops any conditions, including non-rugby related ones
Confirm