Parent/Guardian Name of Child or Young Person Date of Birth Doctors Name Doctors Telephone No: Doctors Address: My child is under 16 years of age and I authorise Beaconsfield Golf Club to arrange for my child to receive essential medical treatment from a qualified medical practitioner at a hospital, or other medical centre, if necessary. My child is 16 years of age or over and I acknowledge that he/she has the right to decide for himself/herself on the treatment to be received or the need to attend a hospital or medical centre. In the event of any medical attention being administered, I understand that Beaconsfield Golf Club will inform me of the action/s taken. Does your child experience any conditions requiring medical treatment and/or medication?
Please select Yes No If YES then please give details, including medication, dose and frequency: Does your child have any special dietary requirements?
Please select Yes No If Yes then please give details What additional needs, if any, does your child have, e.g. needs help to administer planned medication, assistance with lifting or access, regular snacks? please give details: Please now record any medication which are NOT to be administered I confirm that to the best of my knowledge my child does not suffer from any medical condition other than those detailed above. 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. Signed (Parent/Guardian) Date Telephone Number Work Telephone Number
