British AUC Sport - Football Trials & Academy Trips

Please complete all sections accurately. All information is confidential and used only for medical and safety purposes.

Personal Information

Name (as appears on passport)

Nationality

Home Address

Contact Phone Number

Country you are currently living in

Date of Birth

Registered Dr (name of surgery, physician, contact or address)

Emergency contact information (next of kin, name, relationship, contact number and home address)

Family History - Have any of your immediate family had...

If you have ticked any of the questions above, please elaborate

Personal History - Have you had/ Do you have

If you have ticked any of the questions above, please elaborate

Have you had/ Do you have

If you have ticked any of the questions above, please elaborate

If you have ticked Yes for any of the above, please provide the following details

Have you taken any prescriptions in the last 12 months?

Substance prescribed

Reason

How long you have been prescribed the medication (if applicable)

Are you currently taking said prescription (if applicable)

Who has prescribed the medication

Do you have any Allergies?

Substance/Cause

Last episode

Type or Reaction

Medication prescribed

I acknowledge that all information given is factual and consent for information to be reviewed and used by BRITISH AUC SPORT/MEDICAL TEAM.

I understand that failure to provide Medical details to BRITISH AUC SPORT is a breach of Contract and may result in actions taken.

I acknowledge that all Medical information given is factual and up to date for my Son/Daughter prior to taking a place up at the BRITISH AUC Academy.