Whitley Wolves Junior Football Club

Medical Consent Form 2011/2012.

I, the Parent/Guardian* of:

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Give permission for the coaches of Whitley Wolves Junior Football Club and other suitably
qualified assistants participating in football associated activities, to administer any relevant
treatment or medication to the named participant, when or if necessary.

Health Details:
Please give details of any illnesses, disabilities, or medical conditions. This need not
necessarily prevent the participant from taking part, but will make us aware and may
prevent potential problems. (All information is stored under the strictest confidence)
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If none please initial here: ……………….

In addition, if the case arises, I authorise the members of staff described above to take my
above child to hospital and I have full permission for any required treatment to be carried
out in accordance with the hospital diagnosis. I understand that I will be notified by the club,
as soon as possible, of the hospital visit and any treatment given by the hospital.

In correspondence with the club Website Permission Form, do you object to your child being
photographed for the club website, and other promotional uses? YES / NO*

Parents/Guardians* consent:
I have read the above terms and conditions and I have given all the requested information
to be best of my knowledge.

Parents/Guardians* Signature:
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Parents/Guardians* Print:
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Relationship to participant:
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Contact Mobile Number (s):
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Contact Email Address (es):
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All fields required. *Please delete as required.

Whitley Wolves JFC is an Official FA Charter Standard Club.

Website: www.whitleywolves.org.