Fillable Form Nippers 2021-22 Enrolment Medical Surf Port Elliot (Australian National University)

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Form Nippers 2021-22 Enrolment Medical Surf Port Elliot (Australian National University)

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File type: PDF

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Port Elliot
Surf
L
ife
Saving
Club
I
nc.
A.B.N
44 811 071 674
Nippers
Medical
Enrolment
Form
2021-22
NIPPER Details:
Surname:
..............................................................
First
Name: .............................................. Date
of
Birth:
............./
............/.........
PARENT/CAREGIVER Details:
Surname:
..............................................................
First
Name: ..............................................
Address: .............................................................................. ..................................................................................................................
Post
Code:
.....................................
Parent/Carer
Mobile
Number:
.....................................................................................................
Email: .......................................................................................................................... ..........................................................................
(No need to complete if same as above)
Surname:
..............................................................
First
Name: ..............................................
Address: ................................................................................................................................................................................................
Post
Code:
.....................................
Parent/Carer
Mobile
Number:
.....................................................................................................
Email: .......................................................................................................................... ..........................................................................
Medical Conditions:
Is there any
illness, impairments or diaability that your Leaders need to be aware of: No Yes
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………
Does your
child
have
Ambulance Cover No
Yes
Does your
child
have
Epilepsy: NO
Yes
If yes give details of treament …………………………………………………………….
Does
your
child
have
any
Allergies: No
Y
es
–
please
name:
...................................................................................................................................................................................
Does
your
child
use
an
epipen
or
anapen
for
anaphalaxis? No
Yes
Does
your
child
have
Asthma? No
Yes
–
do
they
need
to
take
medication
during
the
session?
No Yes
Asthma Symptoms: ..............................................................................................................................................................................
Has
your
child
had
an
operation
or
serious
illness
in
the
last
6
months? No
Yes
Details: .................................................................................................................................................................................................
Other
medical
conditions
that
we
may
need
to
know relevant to our Nipper Programme: .
..............................................................................................................................................................................................................
If
answering
yes
to
any
of
the
above
medical
conditions
please
attach
their
detailed
emergency
medical
plans
Do You Believe Your Child Needs Extra Suport to Participate in the Beach Activities Yes
No
If answering YES a parent/ caregiver / other qualified person will be required to be with your child at all times.
Give details bel ow
……………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………..
Payment has been made via members portal:
Yes No Via Sports Voucher
Nipper Kid Yes Carnival Kid Yes
Port Eliot
Surf
L
ife
Saving
Club
I
nc.
A.B.N
44 811 071 674
Media
I/We grant permission for Port Elliot SLSC to use, reproduce and communicate (in hardcopy or electronic
format) any photographs, audio and/or video recordings taken of our members for the following
purposes: PESLSC publications and promotional activities (including but not limited to PESLSC website
and social media sites and promotional and marketing materials). I acknowledge and agree that this may
result in public disclosure of my image: Yes No
Code of Conduct
I/We have read the code of conduct for Nippers/Parent/Age Leaders on the website: Yes No
Along with the code of conduct Nippers must be aware of the following:
• Wear their club caps at all times during club activities.
• Wear any form of sun safe beach attire suitable for water/beach activities
• Apply sunscreen and bring my drink bottle for nipper activities
• Don’t do anything when wearing club attire that could damage YOUR CLUB’s reputation
Thank
you
for
taking
the
time
to
complete
this
Participant
Medical/Enrolment
form. It
will
be
used
to
ensure
that
our instructors
are
adequately
prepared
and
aware
of
what
to
do
in
case
of
emergency. We
understand
that
the
information
you
have
provided
is
confidential
and
will
be
treated
as
such.
I
certify
that
the
information
contained
within
this
form
is
correct,
and
up
to date.
I
agree that
a
parent
/
carer
/
responsible person
will
be
present
on
the
beach
or nearby in case
of emergency
at all times.
Parent/Caregiver Signature: ……………………………………………………….. Date: …………………………………….
(if applicable)
Parent/Caregiver Signature: ……………………………………………………….. Date: …………………………………….
PO
Box
21
Port Elliot
South Australia, 5212
Email:juniors@portelliotslsc.com.au
Web:www.portelliotslsc.com.au
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Form Nippers 2021-22 Enrolment Medical Surf Port Elliot (Australian National University)

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Completed 28 September 2021

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