TIP/Rep Nominations

First Name *

Surname *

Date of Birth *

Address *

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Primary email contact *

Primary phone contact *

Parent's Name (if U18)

Parent's Email (if U18)

Parent's Phone (if U18)

Club *

Preferred Position #1 *

Preferred Position #2 *

Any other comments

Emergency Contact Name *

Relationship *

Emergency Contact Number *

Medical Practitioner *

Medical Practitioner Phone *

Medicare Number *

Private Health Insurance Provider

Does your child suffer from any of the following medical conditions

AsthmaDiabetesAllergiesHepatitis B/CGlandular FeverTravel SicknessHeart DiseaseEpilepsyBlood Pressure AbnormalitiesRheumatic FeverJoint InjuriesSleepwalkingOther (please specify below)

Other Medical Conditions

List any medications prescribed by a medical practitioner

Do you give permission for BNA officials to seek appropriate medical help for your child? *

YesNo

Is your child permitted, if necessary, to receive a blood transfusion? *

YesNo

Is your child permitted, if required, to receive anaesthetic? *

YesNo

Can your child take ASPIRIN? *

YesNo

Do you consent to your child being provided PARACETAMOL as required? *

YesNo

Do you consent to your child being provided NUROFEN as required? *

YesNo

Are you/Is your child allergic to PENICILLIN? *

YesNo

Are you/Is your child immunised against TETANUS? *

YesNo

*

By checking this box you give permission for the officials of Brisbane Netball Association to obtain medical attention for you/your child as required

*

By checking this box you give permission for photos or video of you or your child to be used by BNA for various internal and external publications including for use on the website and social media forums and/or for internal analysis

By checking this box you give permission for your child to travel in a car/bus driven by a Brisbane Netball Association official as and when required

*

By checking this box you are committing to the programs in full and meeting all associated costs, if selected

Brisbane Netball Association

TIP/Rep Nominations

BNA Representative Nomination 2016

UNDERSTANDING YOUR MEDICAL HISTORY This MUST be completed by a parent/carer if nominee is under 18

IN CASE OF ACCIDENT...

DECLARATIONS

Verification