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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: juniors@golfvic.org.au
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: __________________