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

First Name(s): ______Surname: ______

Parent’s names: ______

Date of Birth: ______Age: ______Male / Female

Address: ______P/Code: ______

Home Phone: ______Mobile: ______

Emergency Contact Name and Number: ______

Email: ______

Do you/ your child suffer or have suffered from: Details:

Heart Problems Yes / No ______

Joint Problems Yes / No ______

Blood Pressure Yes / No ______

Respiratory Yes / No ______

Asthma Yes / No ______

Epilepsy Yes / No ______

Diabetes Yes / No ______

Pregnant Yes / No ______

Recent Surgery Yes / No ______

Recent Illness Yes / No ______

Medication Yes / No ______

Special Needs Yes/ No ______

Other: Allergies/ Behavioural ______

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.

Doctors Name: ______Phone: ______

Medicare Number: ______Ambulance Cover: Yes / No

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.

Signature ______Date ______