ATHLETE CONSENT FORM – January School Holiday Program

ATHLETE’S NAME: ______

ATHLETE’S DOB: ______/______/______

PARENT/GUARDIAN NAME: ______

CONTACT NO: ______

EMAIL ADDRESS: ______

PROGRAM ACTIVITIES:

  • Athletes will be undertaking a range of fitness and physical activities involved in developing skills for their sport. The inherent risk level is considered to be Low/Medium with the chance of soft tissue injuries occurring such as sprains and strains associated with the normal activity of the chosen sport.
  • Athletes will be using sporting and fitness testing equipment and will be fully supervised by trainedstaff.
  • The sessions may be conducted both indoors (on a netball/basketball court) or gymnasium as well as outside on sporting grounds andfields.
  • All activity is led by qualified and experienced trainers along with professional athletes andcoaches.
  • Transportation – All athletes are to make their own travel arrangements to and from the venue unless other arrangements have beenmade.
  • Dress code – Athletes should wear/bring appropriate clothing and footwear to undertake their sport, along with runners to participate in fitnesstesting.
  • During outdoors sessions, sunscreen will be available – it is the athlete’s responsibility to use and reapplysunscreen.

CONSENT

Pleasecompletetherequiredinformationandcheckallappropriateboxesbelowtoindicateyouragreement/consent:

☐I am enrolling my child in the following program (please tick relevant dates)

☐Monday 23/1/17☐Tuesday 24/1/17

☐Ihave read alloftheinformationcontainedaboveinrelationtotheactivityandIamawarethatwhilepublicliabilitycoversallparticipantsat the venues,EliteAthletePerformanceNetworkdoesnothavepersonalaccidentinsurancecoverforstudents.

☐Igiveconsent for mychild,______(printchild’sname)toparticipateinthisElite/SMJFL Program includingthosepointsdetailedabove.

☐Intheeventofan accident orillness,IauthoriseElitestafftoobtainoradministeranymedicalassistanceortreatmentmychildmayreasonablyrequire.

☐Iacceptliabilityforallcostsincurredinobtainingsuchmedicalassistanceortreatment(includinganytransportationcosts)andundertaketoreimburseElitethefullamountofanycostsincurredonmychild’sbehalf.

Pleasecommentonanyallergies,dietaryrequirements,currentmedication,chronicillness,etc.thatyour child may have:

______

I understandthenatureofthisprogram.IalsounderstandthatEliteAthletePN will takeallreasonablecaretoprevent injury tomychildandthatit will notbeliable for injuriesoccurringduetofactorsbeyonditscontrol.

Parent/Carer Name: ______

Parent/Carer's Signature: ______Date:______/______/______

Once you have completed this form and the payment form below you have two options to return them:

1. Send the completed forms to

2. Print, sign and send to 344 Swan Street, Richmond, VIC, 3121.

ATHLETE PAYMENT FORM –

January School Holiday Program

ATHLETE NAME
PAYMENT
DETAILS / TotalAmount $ (PLUS2%CREDITCARDPROCESSINGFEE)
CREDIT CARD PAYMENT / ☐VISA ☐MASTER CARD
Card Number ______- ______- ______- ______
CVC ______
Card Expiry Date ______/ ______/ ______
CARD HOLDER DETAILS / IauthoriseEliteAthletePerformanceNetworktodebitmycredit card with the amountshownabove(including2%processingfee).
Name on Card ______
Signature (Electronic or printed) ______
Date ______/ ______/ ______
OR
CHEQUE PAYMENT / ☐I am paying by cheque
(Please make cheques payable to Elite Athlete Performance Network)

*PLEASE NOTE :

  • $99 (inc GST) for 1 day of the program.
  • $149 (inc GST) for 2 days of the program.

Once you have completed this form and the consent form above you have two options to return them:

1. Send the completed forms to

2. Print, sign and send to 344 Swan Street, Richmond, VIC, 3121.