Full name of athlete . .. Date of Birth . .
Address . .
Emergency contact
Mobile Work . Home ..
Alternative contact : Name . .. ...Work . Home .
Does the athlete suffer from any of the following (please tick)
O Respiratory problems O High Blood Pressure O Asthma/Bronchitis O Diabetes O Epilepsy O Allergies O Headaches/Migraines O Eye/Ear Problems O Digestive Disorder O Skin Problem O Other (please give details)
If you selected any of the above, please give details
Date of last tetanus vaccination .. ..
Any pre-existing injuries ..
Will the athlete require to take any medication during the camp? Yes/No
If yes, give details .
If athlete is under 16, all medications should be given to the camp leader on arrival with specific instructions.
Any special dietary needs?.....................................................................................
Medicare number .
Any other relevant information? .
I confirm that all information provided above is true and correct and give my consent for the athlete named above to attend the event and for JudoWA to seek and authorize medical or other assistance as may be required.
Note: No responsibility can be taken by JudoWA for expensive electronic items (eg Cameras/Ipods/phones etc).
Signature of Athlete . .
Signature of Parent/Guardian (if under 18) .
Date .