Team Member Medical – Queensland Weightlifting

Qld Team Member Medical Details (CONFIDENTIAL)

Name *

First

Last

Date of Birth *

Address *

Address Line 1

City

State / Province / Region

Postal Code

Phone *

Medicare Number *

Private Health Insurance *

Emergency Contact Details

Primary Contact Name *

First

Last

Relationship to Athlete *

Primary Contact Phone *

Secondary Contact Name *

First

Last

Relationship to Athlete *

Secondary Contact Phone *

Medical Conditions

Diabetes *

Asthma *

Respiratory *

Allergies *

Travel Sickness *

Blood Pressure *

Epilepsy *

Medication Allergies *

Operations *

Other Medications *

Other Conditions *

Significant Medication Details

If you are taking significant medication which medical professionals may need to know in case of an emergency, please provide the following information:

Name of Medication

Dosage

Time(s) dosage to be taken

Any other details

Any other relevant medical information

Please specific any other relevant information that QWA Team Officials or Emergency Medical Personnel should be aware of

Declaration *

I declare that the information provided in this form is correct and complete.

ABOUT THE QWA

Our aim is to develop the sport of weightlifting in Queensland, and to strengthen the friendship and co-operation amongst competitors and officials both here and in other states.

Email: qwa@qwa.org Phone: 0438 031 377

Emergency Contact Details

Medical Conditions

Significant Medication Details

Any other relevant medical information

BECOME A QWA MEMBER

FIND A CLUB AND START LIFTING

COMPETITION CALENDAR

QUALIFYING INFO

FOLLOW US ON INSTAGRAM

ABOUT THE QWA

FOLLOW US