Sports Council NI Home Page >>� Child Protection Good Practice >> Medical Consent Form

Medical Consent Form

This form should be completed by a parent/guardian before your child can participate in a club activity.� One form should be completed for each child/young person.

Name:___________________________________________________��������

Date of Birth: ___________________

Address:_________________________________________

________________________________________________________________
Post Code: _____________� Telephone Number: ________

_______�

Contact Address (if different to above): ________________

__

________________________________________________________________

Post Code: _____________� Telephone Number: ________________
(if different to above)

School:_________________________________________

_________

Name of Doctor: __________________________________________

Doctor�s Address: ___________________________________

______

________________________________________________________

Doctor�s Telephone No: __________________

__________________

Child�s Medical Number: ___________________

Any specific medical conditions requiring medical treatment and/or medication?

�

Any allergies?

Any contact with contagious or infectious diseases within the last four weeks?

Yes��������� If Yes, give details:��

������� ___________________________________________________
� No�������

Please provide any special dietary requirements and the type of pain/flu medication that may be given.

________________________________________________

____________

________________________________________________

____________
___________________________________________________________

Parental Consent (to be signed for competitors under 18 years)

�

I, ___________________________ being parent/guardian of the above named child hereby give permission for the Team Manager to give the immediate necessary authority on my behalf for any medical or surgical treatment recommended by competent medical authorities, where it would be contrary to my son/daughter�s interest, in the doctor�s medical opinion, for any delay to be incurred by seeking my personal consent.

Name: ____________________________________

_________________

Signature:__________________________________________________
(consent by parent/guardian)

Date ________________

�

NB.� Please note that a young person can give their own consent for medical treatment if they are over 16.