Sports Council NI Home Page >>  Child Protection Good Practice >> Medical Consent Form

Medical Consent Form

This form should be completed by a parent/guardian before your child can participate in a club activity.  One form should be completed for each child/young person.

Name:___________________________________________________        

Date of Birth: ___________________

Address:_________________________________________________

________________________________________________________________
Post Code: _____________  Telephone Number: _______________ 

Contact Address (if different to above): __________________

________________________________________________________________

Post Code: _____________  Telephone Number: ________________
(if different to above)

School:__________________________________________________

Name of Doctor: __________________________________________

Doctor�s Address: _________________________________________

________________________________________________________

Doctor�s Telephone No: ____________________________________

Child�s Medical Number: ____________________________________

Any specific medical conditions requiring medical treatment and/or medication?

Any allergies?

Any contact with contagious or infectious diseases within the last four weeks?

Yes          If Yes, give details:  

        ___________________________________________________
  No       

Please provide any special dietary requirements and the type of pain/flu medication that may be given.

____________________________________________________________

____________________________________________________________
___________________________________________________________

Parental Consent (to be signed for competitors under 18 years)

I, ___________________________ being parent/guardian of the above named child hereby give permission for the Team Manager to give the immediate necessary authority on my behalf for any medical or surgical treatment recommended by competent medical authorities, where it would be contrary to my son/daughter�s interest, in the doctor�s medical opinion, for any delay to be incurred by seeking my personal consent.

Name: _____________________________________________________

Signature:__________________________________________________
(consent by parent/guardian)

Date ________________

NB.  Please note that a young person can give their own consent for medical treatment if they are over 16.