Parklands Netball Club Inc. c/- Darebin YMCA 857 Plenty Road, Reservoir 3073 [email protected] www.parklandsnetballclub.org Please return form with registration forms Player Name:____________________________________________________Date of Birth:_______________________ Address: _________________________________________________________________________________________________ ________ Suburb: _______________________________________________________________________ Postcode: ________________________ Parents/Guardian 1 Name: ___________________________________________ Mobile: _________________________________ Parents/Guardian 2 Name: ___________________________________________ Mobile: _____________________ Emergency Contact (if not Parent /Guardian 1 or 2) Name:_____________________________________ Relationship: __________________________Phone:______________________ Ambulance Subscriber: Yes / No Member No: _____________________________________ Medicare Number: _________________________________ Expiry date: Medical History & Treatment Consent Does your child have any medical condition which may require our attention during matches or training? If so please advise: _____________________________________________________________________________________________________ ______________________________________________________________________________________________________ _______________ If a problem arises relating to this condition what action should be taken? ______________________________________________ __________________________________________________________________________________________ _______________ Do we have: Permission to apply ice Yes / No Permission to lift player from court Yes / No Medical Form 2019