Acton Ealing Whistlers Youth Football Club     Consent/Health/ Form                             I am familiar with the nature of the activities/events organised by Acton Ealing Whistlers for young people         and consent for the young person named overleaf to take part in all such events organised by the club.         to take part in all such events. In case of an emergency, in the event of an illness or any accident requiring         emergency hospital treatment.                   I authorise the medical or dental treatment necessary for the young person named overleaf.                                                           Signed________________________________________. Parent/Guardian Date _______________________                             Has the young person been in contact with any infectious illness in the last nine months.     YES / NO                             If yes please give details                                                                                                                                                                   Does the participant suffer from asthma, hat fever, migraine, fits or faints, or any other illness.     YES / NO                             If yes please give details                                                                                                                                                                   Is the participant allergic to anything (e.g. Antibiotics, Elastoplast, aspirin, or any other medicines,         any particular food etc)?             YES / NO                             If yes please give details                                                                                                                                                                   Is the participant receiving long term medical treatment?         YES / NO                             If yes please give details of illness and treatment.                                                                                                                                                               Date of last tetanus injection, if known                                         Name and address of Doctor                                                                                                                   Doctors telephone number                                           Any additional information