I agree for my son/daughter taking part in all activities for junior members of Llandaff Rowing Club.

 

Full Name of child:   _______________________________________________________________

 

Date of Birth:   ____________________________________________________________________

 

Address:_________________________________________________________________________

 

             __________________________________________________________________________

 

             __________________________________________________________________________

             

 

1. Emergency Details:

 

          i. I agree to my child being given any medical, surgical or dental treatment including general             anaesthetic and blood transfusion, as considered necessary by the medical authorities present.

 

     ii. I may be contacted by telephoning the following number/s

 

        Home (full number): ___________________________________________________________

 

        Mobile:  _____________________________________________________________________

 

        Work (full number):  ___________________________________________________________

 

        My home address is:  ___________________________________________________________

 

                                          ____________________________________________________________

 

                                          ____________________________________________________________

 

                                          ____________________________________________________________

 

                      


    iii. Please state an alternative emergency contact point:

 

        Name:  ______________________________________________________________________

 

       Address:   ____________________________________________________________________

 

                        ____________________________________________________________________

 

                        ____________________________________________________________________

 

                        ____________________________________________________________________

 

       Telephone number/s:  ___________________________________________________________

 

  iv. Child Health Service details:

 

     Medical card number:  ___________________________

 

     Family Doctor (name, Address and telephone number):

 

     __________________________________________________________________________

 

    ___________________________________________________________________________

 

    ___________________________________________________________________________

 

2. Medical Information

(Cross out the YES or NO whichever does not apply)

Does your child suffer from the following conditions?

 

If yes to any of the above I please provide details:

_________________________________________________________________________________

 

_________________________________________________________________________________

 

_________________________________________________________________________________

 

 

Does your child suffer from any other condition requiring medical treatment, including medication?

 

YES/NO

 

If YES, please provide full details:

 

_________________________________________________________________________________

 

_________________________________________________________________________________

 

Has your child been immunised against the following diseases?

 

Poliomyelitis YES/NO

Tetanus YES/NO

 

If YES to tetanus, please give date:    __________________________________________________

 

Is your child taking any other form of medication on a regular basis?

 

YES/NO

 

If YES, please give full details, indicating the type of medication and dosage:

 

_________________________________________________________________________________

_________________________________________________________________________________

Please ensure your child has adequate supplies of medication and dosage at all times when using the club or when at external events

 

 

To the best of your knowledge, has your child been in contact with any contagious or infectious diseases, or suffered any recent condition that may becomes infectious or contagious?

 

YES/NO

 

If YES, please give full details:

 

_________________________________________________________________________________

 

_________________________________________________________________________________

 

 

 

3. Insurance Cover.

 

I understand that as a Junior Member of Llandaff RC my child is insured in respect to legal liabilities (third party liability) but has no personal accident cover.

 

I understand that any extension of insurance cover is my responsibility.

 

4. Declaration.

 

ü      My child and I will read and understand all information related to any activities or visits Llandaff RC Junior Member may be involved in and also the Llandaff RC Rules and Regulations which are available at the club or via the club secretary.

 

ü      I understand the insurance cover for Junior Members at Llandaff RC

 

ü      I consent for my child _______________________________ to take part in all

            activities organised and available for Junior members of Llandaff Rowing Club and declare                                                          

            that my child is in good health and physically able to participate in all activities.

 

ü      I consent/ do not consent (delete as applicable) for my child ________________________________ to be filmed or photographed as part of their training or competition activity. Video film may sometimes be used to assess and inform athletes of their technique and progress.

 

ü      I am responsible for my child travelling to and returning from Llandaff RC and for their safety and conduct at any regatta or event my child competes or attends when representing Llandaff RC.

 

ü      I will ensure that any change of circumstance, concerning my child's participation at Llandaff RC, will be notified to the club as soon as possible.

 

 

Signature of parent/guardian:

 

 

 

 

Name in block capitals ___________________________________________ Date ____________________