2015 BURTTA CHENEY GIRLS ASSESSMENT CAMP Anglesea Golf Club & Camp Wilkin 28 – 30 June, 2015 (9 – 17 years) Entry Form TAX INVOICE – ABN: 26 589 569 172 Name (Block Letters) (First Name) (Last Name) Golf Club Address Suburb State Postcode Date of Birth (Compulsory) // Parent Contact during camp Home Phone Email  GOLFLink Number Handicap Expression of interest for Mini Bus (cost to be determined by numbers, approximately $35) Signature Date I will adhere to Golf Victoria’s Code of Conduct for the duration of the camp. PAYMENT DETAILS: Card Number Expiry Date Cheque/Money Order (Please make Cheques payable to Golf Victoria)  MasterCard  VISA      $400.00 / Contact Number Entry Fee Signature TOTAL Name on card Entries close at 5.00pm on Friday 6 June, 2015 Return to: Golf Victoria PO Box 287 Mulgrave, VIC 3170 Phone: (03) 8545 6200 Fax (03) 9543 9307 Email: [email protected] Medical Information Form Personal Details: Name (Block Letters) (First Name) (Last Name) Address Suburb State Postcode Mobile Phone Home Phone Date of Birth (Compulsory) // Emergency Contact Details: Name (Block Letters) (First Name) (Last Name) Relationship Address Suburb State Postcode Mobile Phone Home Phone Work Phone Doctors Details: Name (Block Letters) (First Name) Phone Medicare Number Ambulance Member Yes / No (Last Name) Medical Information Form Current Medical History Do you take any form of medication, if so what (state name and dosage)? _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Do you suffer from any allergies? If so what are they? _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Do you have any current (or recent) medical problems? _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Do you have a history of any previous sports injuries or any recurring injuries? _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Do you have any special dietary needs? Please specify. _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Medical Information Form I consent to my child taking part in this event/camp/tournament and where the person in charge of the event/camp/tournament is unable to contact me, I authorize the person in charge to:  Consent to my child receiving medical or surgical attention as deemed necessary by a medical practitioner in the event of any illness or accident.  Administer or consent to such a first aid as the person in charge may judge to be reasonably necessary. I accept all risks involved in the administration of medical, surgical or first aid treatment considered necessary and the responsibility for payment of all expenses incurred in relation to such treatment and any emergency transportation required. I accept that my child may be returned home early from the event/camp/tournament or activity in the event or serious misbehaviour and that any costs associated with this will be met by me. Player Signature: __________________________________________ Date: __________________ Parent Signature: __________________________________________ Date: __________________