ASC SWIMMERS MEDICAL PROFILE FORM

Please enter your swimmers full name *

First

Last

Email *

Swimmers date of birth (please input date dd/mm/yyyy) *

Gender *

Male
Female
Non-binary
Prefer not to say

Emergency contact full name *

Emergency contact phone number *

Emergency contract relationship to swimmer *

Current History - please list all medical issues and email action plan if applicable, please type NIL is not applicable: *

Sports Injuries (please any injury which is current/recurring, please type NIL is not applicable): *

Regular medications including supplements – please state name and dosage or NIL if not applicable: *

Allergies (Medication and Food) *

Comment or Message

Informed Consent and Acknowledgement *

I, as the Swimmer or Parent/Guardian, (in respect to an applicant under the age of 18 years): 1. understand that Swimming WA and the Australind Swimming Club will be responsible for handling personal information. This is for emergency contacts and medical information and personal information will not be passed on to any other third party (other than the coaches) without the applicant’s consent. 2. assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Australind Swimming Club and all its respective officers, agents, and representatives from all liability for injuries to said child participating in or conducted during the sessions. 3. consent for my child to be administered such emergency medical treatment as is reasonable/necessary and that I will reimburse any necessary expenses incurred. 4. hereby waive all claims against Australind Swimming Club including all coaches and affiliates, all participants, and, if applicable, owners and lessors of premises used to conduct the event. I have read, understood, and agree to the above declarations.

Consent and Acknowledged by: *