Canoe Polo Form

Participant Information

Gender MaleFemale


Are you a Paddle SA member (required)




Medical Conditions (required)
Please list relevant information, including any medication and dosage in the medical information box.
All the below conditions require a response
Asthma
Diabetes
Dizziness/Blackouts
Epilepsy/Seizure/Convulsions
Heart disease
Blood pressure issues
Allergies
Does the participant carry medications to be administered during the event?
(e.g. Tablets /capsules, Insulin / Ventolin?)
Is there other information of which we should take note (e.g. dietary requirements, hospitalisation/surgery)

list relevant information, including any medication and dosage

In circumstances where it is impracticable or impossible to communicate with me, I Authorise Paddle SA’s delegated officials or agents to obtain such Medical or Dental treatment, including any essential transfusion of blood, that a qualified Medical or Dental Practitioner considers necessary, and I Accept any necessary associated expenses that are incurred.

Registrant U16 years old? (required)

I will join the group breakfast at local cafe (at own cost) (required)