PERTH YOUTH FUTSAL

Parental Consent Form

Valid until 31 December 2007

Team
Age Group
Personal Details:
Players Name:
Date of Birth:
Address:
Postcode:
Telephone Number:
Medical Details:
Name of Doctor:
Telephone Number:
Emergency Family Contact Name:
Telephone Numbers:
Allergy to any medication / substance - Details
Currently taking medication - Details
Other:
Permission for inclusion in Perth Youth Futsal publicity photos (Note: these photos may be published in the local press and the Perth Youth Futsal website: scottishfutsal.co.uk)
YES	NO
I consent to the above named youth participating in Perth Youth Futsal activities. I agree to my son/daughter receiving emergency medical / surgical / dental treatment as considered necessary by the medical authorities present. I accept that Perth Youth Futsal organisers & coaches cannot be held responsible for any loss / damage / injury caused or incurred by my son / daughter during the sessions.
Name:
Signed
Date: