KENSINGTON FLEMINGTON JUNIOR SPORTS CLUB PLAYER MEDICAL FORM AUSTRALIAN RULES

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Harold Reynolds
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1 KENSINGTON FL E MIN G T O N KENSINGTON FLEMINGTON JUNIOR SPORTS CLUB PLAYER MEDICAL FORM AUSTRALIAN RULES Junior Sports Club Since 1935 The following Medical Form must be completed prior to the start of the season. Your child s trainer shall review the medical form with you, in person, prior to their first game. The KFJSC is guided by the policies and guidelines set out buy the AFL and Sports Medicine Australia. These are referenced and can be found on our website at Name: DOB: Age Group: Parent Name: Contact Numbers 1 Home: Mobile: Contact Numbers 2 Home: Mobile: The following information is required for each child participating in sport with KFJSC. Please complete questions where the response is yes. ASTHMA Yes p No p 1. Does your child have an asthma plan? Yes p No p 2. If yes can you provide a copy? Yes p No p. 3. Will you supply the child s spacer & reliever each match day? Yes p No p 4. OR Will you supply child s spacer & reliever for trainer to hold for season? Yes p No p CONCUSSION EPISODE 1. Has your child ever sustained or been suspected of sustaining concussion? Yes p No. p 2. Please provide an approximate date of when a concussion incident/s occurred? 3. What treatment was initiated? Tick any that applied. OBSERVATION IN HOSPITAL p ADMISSION TO HOSPITAL p SCANS p REST AT HOME p DAYS OFF SCHOOL p WEEK/S OFF SPORT p 4. How long did your child take to recover? ONE DAY p A FEW DAYS p ONE WEEK p MORE THAN ONE WEEK p 5. Do you have a GP to visit for review of your child before returning to school and to sport? Yes p No p

2 FRACTURE/DISLOCATION/SPRAIN SUSTAINED Fractures: Yes p No p 2. How long ago did the fracture occur? 4 Can you provide the treatment plan? (eg. Physio exercises/taping instructions etc) Yes p No. p Dislocations: Yes p No p 2. How long ago did the dislocation occur? 4. Can you provide the treatment plan? (eg. Physio exercises/taping instructions etc) Yes p No. p Sprains: Yes p No p 2. How long ago did the sprain occur? 4. Can you provide the treatment plan? (eg. Physio exercises/taping instructions etc) Yes p No. p ALLERGIES Yes p No p If YES, please list: 1. How does your child react? 2. What is the treatment if exposed to the allergen? 3. Will you have treatment available each game day? 4. Is there any other medical information of relevance that trainers should be aware of?

3 OTHER MEDICAL CONDITION p Yes p No Please describe, including treatment requirements and relevant information: Office Use Only: Date of interview: Trainer: Name: Parent/Guardian: Name: Signature: Signature:

4 FOR PLAYERS / PARENTS TO RETAIN CONCUSSION INFORMATION: Please refer to All trainers have a copy of the AFL Management of Concussion Guidelines and follow the principles contained within the document. All trainers have a flow chart for the detection and management of traumatic brain injuries. All trainers have a copy of the Pocket Concussion Recognition Tool. These tools help recognise a concussion. However they do not replace a more comprehensive medical review. At KFJSC all trainers strongly recommend review by a qualified GP the day of the incident and prior to the child returning to school and returning to sport. This may take several days to several weeks and no child can return to sport until the medical clearance has been given. This onus of responsibility is with the parent. HELMETS: Please refer to page 14 There is no definitive scientific evidence that helmets prevent concussion or other brain injuries in sport. There is some evidence that younger players who wear a helmet may change their playing style and receive more head impacts as a result. It is not compulsory for children playing football with KFJSC to wear helmets, however it is at the discretion of the parents if they would like their child to wear a helmet. MOUTHGUARDS: Please refer to page 14 There is no definitive evidence that mouthguards prevent concussion or other brain injuries in football. However mouthguards have a definitive role in preventing injuries to the teeth and face and for this reason they are strongly recommended at all levels of football. It is compulsory for all children playing football with KFJSC to wear mouthguards (preferably dentally fitted laminated mouthguards). It is not compulsory for the WRFL although this is under consideration. HOT WEATHER GUIDELINES: Compared to adults, children are at increased risk of heat illness- heat exhaustion and heat stroke. It is therefore important that during times of hot and humid weather, steps are taken to minimise the risk of heat illness during training and competition games. Sports Medicine Australia has developed guidelines for use by sporting clubs to allow for safe training and competition. The two key documents that all trainers are familiar with are listed below: Hot Weather Guidelines: For sporting clubs and associations and the physically active Beat The Heat- playing and exercising safely in hot weather There is no precise temperature at which play or training has been shown to become dangerous for all junior sports players. Two measures that can be used as a guide to alter play or training are: 1. Ambient Temperature: most useful on hot, dry days.

5 Risk of heat illness: Temp 26-30oC: Moderate Temp 31-35oC: High-Very High 36oC and above: Extreme 2. Wet Bulb Globe Temperature (WBGT): useful when humidity is high Risk of heat illness: 21-25: Moderate to High 26-29: High-Very high 30 and above: Extreme At times of moderate risk of heat illness, play and training will continue, with steps taken to minimise risk such as additional breaks, modification of warm-up, more frequent use of interchange and additional hydration. In the event that conditions reach High to Extreme, play or training will be modified significantly, including cancellation if required. Real-time ambient temperature and WBGT can be found at the Bureau of Meteorology at INSURANCE: JLT All registered WRFL players are covered under the Australian Football National Risk Protection Programme, operated by JLT Sports. This insurance provides for some reimbursement for non-medicare medical costs and/or loss of income for 12 months from the date of injury. It is important to note that Medicare items and services, including the Medicare Gap are not covered. The level of cover for non-medicare medical costs associated with paraplegia/quadriplegia is caped at $1 million per claim. The JLT Sport Personal Injury Claim Form can be accessed via the JLT website or via the KFJSC website. It is important that any injury and therefore subsequent claim is brought to the attention of your child s trainer or team manager. A claim form should be submitted as soon as possible, even before treatment has been completed.

JLT Sport Personal Injury Claim Form

JLT Sport Personal Injury Claim Form Who should use this claim form? You should complete this form if: Insured - You are a player, umpire, official or volunteer (Insured Person) of a League/Club (the Insured) covered within the AFL National