<p> Moorooka Marlins Amateur Swim Club Moorooka State School Cnr. Sherley and Beaudesert Rd, Moorooka. 4105 www.moorookass.com.au Pre Screening Questions Program (circle one): Learn to Swim / Wahoo / Mini-Marlins / Marlins/ Adult Aqua/ Staff </p><p>First Name(s): ______Surname: ______</p><p>Parent’s names: ______</p><p>Date of Birth: ______Age: ______Male / Female</p><p>Address: ______P/Code: ______</p><p>Home Phone: ______Mobile: ______</p><p>Emergency Contact Name and Number: ______</p><p>Email: ______</p><p>Do you/ your child suffer or have suffered from: Details:</p><p>Heart Problems Yes / No ______</p><p>Joint Problems Yes / No ______</p><p>Blood Pressure Yes / No ______</p><p>Respiratory Yes / No ______</p><p>Asthma Yes / No ______</p><p>Epilepsy Yes / No ______</p><p>Diabetes Yes / No ______</p><p>Pregnant Yes / No ______</p><p>Recent Surgery Yes / No ______</p><p>Recent Illness Yes / No ______</p><p>Medication Yes / No ______</p><p>Special Needs Yes/ No ______</p><p>Other: Allergies/ Behavioural ______</p><p>If you answered yes to any of the above questions it is advised to seek medical advice from your doctor prior to participating in an exercise program and must inform coaches/instructors of any medical issues.</p><p>Doctors Name: ______Phone: ______</p><p>Medicare Number: ______Ambulance Cover: Yes / No</p><p>I (print Name) ______declare that the information I have given is true and correct to the best of my knowledge. I understand that this information is to be kept confidential and give my permission to the supervising instructor to obtain any medical or assistance they deem to be necessary should any medical emergency occur. I agree to all policy and procedures of Moorooka Marlins Amateur Swim Club.</p><p>Signature ______Date ______</p>