EmailMe Form - PGC JUNIORS - Medical Records Form 2016

PGC JUNIORS - Medical Records Form 2016

We are required to keep records of any possible concerns with regard to your child's health.

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.

It is the responsibility of the junior member and their parent to notify Poulton le Fylde Golf Club of any of the details change at any time.

Name *
First Last
Date of Birth *
MM / DD / YYYY
Home Phone *
Mobile Phone *
Email *
Home Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Doctors Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Does the above member experience any conditions requiring medical treatment and/or medication. *
Does the above member take any medication. *
Does the above member have any disability. *
Does the above member use any form of respiratory aid *
Does the above member have any allergies. *
Does the above member have any specific dietary requirements. *
Does the above member have any communication needs e.g. non-English speaker/ Hearing impairment/ sign language user/ dyslexia. *
• Membership Payment Plan: *
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