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Chairman & Secretary

Bruce Gracie
21 Kings Lane
Newton Regis
Tamworth
B79 0NN

01827 830303
E-mail: kangagym@aol.com

MEDICAL DETAILS AND CONSENT FORM

1 APRIL 2010 - 31 MARCH 2011

Name of Team Member: ___________________________________

Home address: ___________________________________

___________________________________

Post code: _____________

Telephone Number: _____________

Name and telephone)

number to contact ) ___________________________________
in an emergency. )

Name and address ___________________________________

of own Doctor
___________________________________

Date of Birth: ___/_______________/________

National Insurance No: ___________________________________

Is he allergic to anything? (e.g. aspirin, antibiotics, any particular food or drug?) If so give
details:-

____________________________________________________________

Does he suffer from any of the following: asthma, chest complaints, hay fever, migraine, fits
or faints, travel sickness, diabetes, celiac disease or any other illness or disability? If so
give details:-

____________________________________________________________

Is he having any medical treatment at present? If so, please give details of treatment and
medicines, etc.

____________________________________________________________

Date of anti-tetanus injection (if known):- __________________

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Please indicate any dietary requirements:- __________________