Junior Shinty Club Player Details (to be completed by parent/guardian if player is under 18)
Personal Details
Medical Information
Participants Name: ……………………………………………………………… Does your child suffer from any medical condition that may affect their
ability to participate in the activity?
YES/NO
Date of Birth: …………………………………Age: ………………………….
If YES, please give details:….…………….............................................
Address:
Does your child suffer from any additional support needs? (This will help us
……………………………………………...........................................……..
with planning the sessions)
YES/NO
………………………………………………………..................................….
If YES, please give details:….…………….............................................
..................................................................... Postcode:……………………
Have they received a tetanus injection in the past 5 years?
YES/NO
Telephone:…………………………………………………………………..….
Are they currently taking any medication?
YES/NO
Email:
If YES, please give details including name, dosage and frequency:
…………………………………………………........................................…..
…………………………………………………………………………………
Next of Kin: ……………………………………………………………………..
Will this be self administered?
YES/NO
Are they allergic to any medication/substance?
Emergency Contact Details
Please provide details of two people that can be contacted in an
emergency.
Name of emergency contact: …………………..........................................
Telephone: …………………………............................................…………
Alternative Emergency Contact
Name: ………………………………………………………………………….
YES/NO
If YES, please give details:
……………………………………………………………………...................
What action should take place if an allergic reaction occurs?
………………………………………………………………………………….
Name of Doctor: ………………………………………………………………
Surgery Address: ……………………………………………........................
Surgery Telephone: .…………………………………………........................
Photographs/videos of shinty matches may be taken and used in press
articles. If you do not wish photographs of your child to be used in this way,
please tick this box.
Telephone: ………………………………...........................................…....
Signed: ……………………………………Date: ………………