Please complete the Medical Details Form below Taree Tigers Hockey Club Medical Details Form 2020 Personal DetailsName* First Last Email* Address Street Address Address Line 2 City State Postcode PhoneMobile PhoneGenderMaleFemaleDate of Birth DD MM YYYY Emergency Contacts1st Contact Name* First Last 1st Contact Address Street Address Address Line 2 City State Postcode 1st Contact Phone1st Contact Mobile1st Contact Relationship2nd Contact Name First Last 2nd Contact Address Street Address Address Line 2 City State Postcode 2nd Contact Phone2nd Contact Mobile2nd Contact RelationshipHealth Care DetailsDoctor’s Name First Doctor's Phone NumberMedical DetailsPlease list any known medical conditions that are relevant to your participation as a hockey playerExamples, neck/spinal injury, head injury, cardiac conditions, epilepsy, asthma, diabetes, allergy etcPlease list any medications you carry with you and may require in case of an emergencyExamples, Ventolin, Glucose, Epipen etc.Have you received a medical clearance from your doctor for the above conditions?YesNoWearing of Protective EquipmentThis includes competition matches and/or trainingDo you wear protective equipment?*YesNoFor example, mouthguard, shin pads, head gearIf yes, please select the protective equipment you wear Shin Pads Mouth Guard Playing Glove Face Mask Other Equipment Please list the other protective equipment you wearTo the best of my knowledge, all information contained on this form is correct* Yes Signature - If under 18 please have a parent or guardian signDate DD MM YYYY Taree Tigers Hockey Club – Player AgreementExclusion of Liability for Damage to a Team Member / Player’s Person or Property and Indemnity as a result of NON wearing of shin pads and/or mouthguard during competition matches or at club training while a registered player with Taree Tigers Hockey Club. I hereby accept there is an inherent and foreseeable risk of receiving a knock to the lower legs and the mouth or a ball striking my lower legs and my mouth in undertaking hockey activities. I acknowledge these risks are why Taree Tigers Hockey Club requests all players to abide by the current Hockey NSW Policy of the compulsory wearing of mouth guards and shin pads. I hereby agree that Taree Tigers Hockey Club and Manning Valley Hockey Association Inc., its Board members, Umpires, Technical Officials and other volunteers shall not be nor be deemed responsible or liable whether in contract, or in tort or under statute, for any injury, illness or other mishap to me or my property sustained in, arising from or out of, or in any way directly or indirectly connected with any match, competition, representative championship, practice or training of whatsoever nature held from the date of this Agreement or in any way directly or indirectly connected with the team or with any medical or scientific examinations, tests or treatments conducted on me from the date of this Agreement as a result of my non-compliance with the Hockey NSW competition safety rule relating to the recommended compulsory wearing of shin pads and mouthguards. I hereby indemnify and will at all times hereafter well and sufficiently indemnify and keep fully indemnified Taree Tigers Hockey Club and Manning Valley Hockey Association Inc., its Board members, Umpires, Technical Officials and other volunteers from and against all actions, suits, causes of action, proceedings, claims, demands, costs and expenses whatsoever which may be taken or made against Taree Tigers Hockey Club or Manning Valley Hockey Association Inc., its Board members, Umpires, Technical Officials and other volunteers or incurred or become payable by Taree Tigers Hockey Club or Manning Valley Hockey Association Inc., its Board members, Umpires, Technical Officials and other volunteers in connection with, or arising out of any such injury, illness or mishap to me or my property arising from my non-compliance and / or refusal to wear shin pads and/or a mouthguard.Player Name First Last Date DD MM YYYY Player SignatureParent/Guardian Signature - if under 18Taree Tigers Hockey Club Registrar SignatureMedical CertificateCopy of medical certificate must be attached to this Medical Form if unable to wear protective equipment such as shin pads and/or mouth guard for medical reasonsCommentsThis field is for validation purposes and should be left unchanged.