Xxxxxxxxx Youth Go Club

The information on this form will be kept and will be disclosed to adults taking children to tournaments on a need-to-know basis. Please ensure that all information that could be needed is provided. Thank you.

Parental Consent and Medical Form

The information on this form will be kept and will be disclosed to adults taking children to tournaments on a need-to-know basis. Please ensure that all information that could be needed is provided. Thank you.

Child's name: ______________________________    Date of birth: _______________

Home address: ________________________________________________________________

              ________________________________________________________________

              ________________________________________________________________

              ________________________________________________________________


Phone number: ______________________________


Emergency contact details: ___________________________________________________


Is your child receiving any medical treatment at present? If so, please give
details.

   ___________________________________________________________________________

   ___________________________________________________________________________

   ___________________________________________________________________________


Please also give details of any  medical  conditions  that  may  affect your
child's performance or that should be notified to doctors or paramedics from
whom emergency treatment may be sought.

   ___________________________________________________________________________

   ___________________________________________________________________________

   ___________________________________________________________________________


Family doctor's name and address:   __________________________________________

   ___________________________________________________________________________

   ___________________________________________________________________________

Family doctor's phone number: ________________________________________________


I agree to the above details being held on computer and disclosed to persons
who may  need  to know.  I accept that I am responsible for the accuracy and
completeness of the details given on this form and for notifying any changes
to these details.  I agree that  a  responsible  adult  may  seek  qualified
treatment  for  my  child  in  the event of an emergency while attending and
travelling to and from a Go tournament.


Signed: _______________________________________  Date: ________________________

 






Last updated Tue Nov 30 2010. If you have any comments, please email the webmaster on web-master AT britgo DOT org.