Middlesex Golf

pARENTAL CONSENT FORM 2018

(Formerly Parent/Guardian Consent Form)

MIDDLESEX GOLF LTD

The safety and welfare of juniors in our care is paramount, and it is therefore important that we are aware of any illness, medical condition and other relevant health details so that their best interests are addressed.

Please complete this form with our assurance that the information will be treated as confidential.

Name
CDH Number
Date of Birth
Address
Telephone Number
Email Address
Emergency Contact No.1
Relationship to Child
Home Number
Work Number
Mobile Number
Emergency Contact No.2
Relationship to Child
Home Number
Work Number
Mobile Number
Medical Information
Doctor's Surgery Address
Telephone Number
Does your child have a European Health Insurance Card?

Does your child experience any condition requiring medical treatment and/or medication?

If yes, please give further details.
Does your child have any allergies?

If yes, please give further details.
Does your child have any specific dietary requirements?

If yes, please give further details.
What additional needs, if any, does your child have e.g. needs help to administer planned medication, regular snacks?
The Disability Discrimination Act 1995 defines a disabled person as ‘anyone with a physical or mental impairment, which has a substantial and long term adverse effect on his or her ability to carry out normal day to day activities’. Do you conside

I consent that my child can travel with a member of the Middlesex Golf staff or its agents to attend fixtures / events away from their Home Club.

I consent to the use of photographs and video clips of my child taken at the above events and activities. I also consent that should my child win any competition, their photo may be published in related sports websites, newspapers or magazines.

I consent to data being shared with England Golf to evaluate the programme and to enable any future regional and national opportunities be communicated to you.

I confirm to the best of my knowledge that my child does not suffer from any medical condition other than those detailed above.
I agree to notify the Middlesex Golf of any changes.
I give permission for the Middlesex Golf responsible person to give the immediately necessary authority on my behalf for any medical or surgical treatment recommended by competent medical authorities, where it would be contrary to my child’s interest, in the doctor’s medical opinion, for any delay to be incurred by seeking my personal consent.
The submission of this form confirms my child has my permission to be on the golf club premises at whichever golf club the County event/match is taking place.

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Juniors

pARENTAL CONSENT FORM 2018

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pARENTAL CONSENT FORM 2018

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