Medical Information / Food Allergies / Emergency Contacts

As a selected Water Polo NSW Representative Player/Coach/Manager I will provide information within the Medical Information/ Food Allergy / Emergency Contact survey, as required.

Below is the link to the Water Polo Australia Code of Conduct

https://cdn.revolutionise.com.au/cups/wpal/files/i0uuhiaegmvtxly7.pdf

Player Full Name*

Player Date of Birth*

Player Medicare Number*

Player Private Health Fund & Policy No (if applicable)

Player Prescribed Medication (if applicable)

Player Allergies (if known)*

Player Food Allergies/Intolerances (if known)*

Family Doctor & Contact Details

Emergency Contact - Name (eg Mum/Dad/Sibling)*

Emergency Contact - Phone Number*

Emergency Contact - Email*

Overseas Travellers please provide your Passport Number. In addition a copy of the passport is to be provided to Team Manager - Roz Caldwell - via email - rozaljlc@gmail.com by Thursday 20th October 2022

I have read and understood the Water Polo Australia Code of Conduct, attached herein to the survey*

Yes

I accept that any instances of poor behaviour or breach of the Code of Conduct that i will be sent home (at my own expense) or otherwise excluded from the Team/Squad.

Yes

© 2025 Water Polo NSW