This Form Is to Be Completed by an Umpire S Parent / Guardian If the Umpire Is Younger

This form is to be completed by an umpire’s Parent / Guardian if the umpire is younger than 18 years or by the umpire himself/herself, if he/she is 18 years old or older.

SURNAME: / CHRISTIAN NAME/S:

EMERGENCY CONTACT:

Name: ______

(Relationship to Umpire) ______
Contact number: ______/

Phone numbers:

Home: ______
Mobile: ______

Medicare Number: ______

Expiry date _ _ / _ _ Position on card ___ / Private Health Fund:
______
Ambulance Subscription: (please circle)
Yes No /

Year of Last Tetanus Injection:

______
Please state briefly any MEDICATIONS, HEALTH ISSUES, MEDICAL ALERTS or SPECIAL NEEDS for which the
AFL Victoria staff needs to be aware.
Asthma plan to be completed over-page.
Please list any food allergies that should be brought to our attention
Do you give permission for your child to be administered Paracetamol (Panadol) by a supervising AFL Victoria staff member for any minor ailments? (please circle) Yes No

I/We hereby request you to include (my/our child): ______

in the: 2016 V/Line Cup

from: Sunday 25 September (arrival) through to Thursday 29 September, 2016

I/We confirm that I/we have read the attached information in respect of the program and my/our consent is

based upon such information. I /We confirm that we are the parents/guardian of my/our child and are authorised

to give this consent.

Whilst I/we understand that AFL Victoria will attempt to take reasonable steps to contact me in the

event of an accident or illness (without being obliged to do so), I/we jointly and severally authorise you

(acting through staff of AFL Victoria) in the event of any accident or illness, to take all such steps as

may in your opinion be necessary for the proper treatment and care of my/our child, and (should you be

advised by a duly qualified and registered medical practitioner that it is necessary) to authorise a

general anaesthetic and/or blood transfusion. I/We agree to reimburse AFL Victoria for all

expenses incurred for such treatment or care.

I/We hereby jointly and severally release and indemnify and hold harmless the AFL Victoria, its

Board members, servants and agents (save for any gross negligence on their part) from any and all

liability whatsoever and howsoever arising in or in connection with my child’s participation in the program.

SIGNATURE OF UMPIRE / PARENT OR GUARDIAN: ______

PRINT NAME/S: ______

Has your child ever had sudden severe attacks requiring hospitalization? ______Yes No

Has your child been admitted to hospital due to their asthma in the past 12 months? Yes No

Does your child need assistance taking their medication? ______Yes No

USUAL ASTHMA MANAGEMENT PLAN

Usual signs of child’s asthma

Wheezing
Tightness in chest
Coughing
Difficulty in breathing
Difficulty speaking
Other (please describe) ______/

Worsening signs of child’s asthma

Increased signs of:
Wheezing
Tightness in chest
Coughing
Difficulty in breathing
Difficulty speaking
Other (please describe) ______/

What triggers the child’s asthma?

Exercise
Colds/Viruses
Pollens
Dust
Other triggers (please describe)
Medication requirements usually taken at school:
(including preventers, symptom controllers, medication before exercise)
Name of Medication / Method
(e.g.puffer & spacer, turbuhaler) / When, and how much?

ASTHMA FIRST AID PLAN

Please tick (√) preferred First Aid Plan:

Victorian Schools Asthma Policy for Emergency Treatment of an Asthma Attack

(Section 4.5.7.8 of Department of education Schools of the Future Reference Guide).
1. Sit the student down and remain calm to reassure the student.
2. Without delay shake a blue reliever puffer (Ventolin, Airomir, Asmol or Bricanyl) and give 4 separate puffs, through a spacer (spacer technique – 1 puff / take 4 breaths from spacer, repeat until 4 puffs have been given).
3. Wait 4 minutes. If there is no improvement, give another 4 separate puffs, as per step 2.
4. Wait 4 minutes. If there is no improvement, call an ambulance (dial 000) immediately and state that “a student is having an asthma attack”.
5. Continuously repeat steps 2 & 3 whilst waiting for the ambulance to arrive.

Student’s Emergency Treatment (if different from above)

· In the event of an asthma attack away from home, I agree to my son/daughter receiving the treatment described above.

· I authorise AFL Victoria staff to assist my child with taking asthma medication should they require help.

· I will notify you in writing if there are any changes to these instructions.

· Please notify me if my child regularly has asthma symptoms at the V/Line Cup.

· Please notify me if my child has received asthma first aid.

· I also agree to pay all expenses incurred for any medical treatment deemed necessary.