GSWP Players Medical & General Indemnity Form

MEDICAL & GENERAL INDEMNITY FORM
PLEASE NOTE THAT NO CHILD MAY PARTICIPATE IN ANY GSWP OR SA SCHOOLS EVENT UNLESS THE INDEMNITY FORM IS COMPLETED AND SIGNED.

I, __________________________________
[Full name and surname of parent/guardian],

the legal parent / guardian of

_________________________________________________________________
[Full name and surname of player / participant]

Participants Age:________

Participants School: ________________________

Cell: _______________________________ hereby give permission for him/her to participate in the sporting activities of Gauteng Schools Water Polo and SA Schools Water Polo ("the Club"), and to go on approved Club tours and excursions related to such sporting activities.

I hereby indemnify and hold the Club, its agents, representatives, coaches and managers harmless against any claim or demand arising from the death of, or injury to, my child or any loss of or damage to property, person or funds, of whatsoever nature and howsoever sustained, including consequential loss, arising from or occasioned by my child's participation, in any such sporting activities and/or such tours and excursions.

I agree that, if in the opinion of the Chairperson of the Club or his delegated deputy, an emergency has arisen and medical treatment be deemed necessary for my child, the Chairperson of the Club or his delegated deputy shall have the authority (which is hereby delegated to the extent such delegation may be required) to consent to such medical treatment, including surgical intervention, on my behalf.

I accept that reasonable precautions will be taken to ensure the safety and welfare of my child and that I will be held responsible for the payment of medical, hospital or other accounts which has accrued applicable to my child.

I accept that I will be held accountable and liable for any actions by me, my child or my proxy that is reasonably deemed so by the Chairperson of the club or his delegated deputy.

As far as I am aware my child is physically and psychologically capable of participating in the said sporting activity and he/she is in good health. However, the persons responsible should please note the following: [Please state aspects that the staff should be aware of, e.g. allergies, tendency towards abnormal bleeding, epilepsy, diabetes, recent injury, relevant surgery, routine medication, etc.]

PLEASE NOTE: _______________________________________________________


The following information is essential in case of medical treatment or hospitalisation:

PARENT TO CONTACT: Name___________________________________
Cell: ___________________________________
tel. W
tel. H
PARENTS EMPLOYER:
Name: _________________________
address: _________________________________
tel.

MEDICAL AID FUND:
Name: _________________________
Membership No: ___________________________
tel.

FAMILY DOCTOR:
Name: _________________________
tel. W
tel. H ________________________________
SIGNATURE OF PARENT/GUARDIAN:___________________________________
DATE:_________________ I.D. NUMBER:_______________________


SIGNATURE OF WITNESS:____________________________________________

DATE:_________________ I.D. NUMBER:_______________________ _______________________________ PLACE