Date of Birth
Home Telephone Number
Country of Birth
Contact Email Address
School Details: incl Telephone number
Medical Details GP Contact Details
Past Medical Allergies
If you have selected any of the above, please supply more information
Do you Suffer from
If you have ticked other, please clarify
In our onging commitment to improve and maintain our duty of care towards all members, we have introduced guidelines regarding the treatment and rehabilitation of injuries sustained by West Bromwich Albion FC Academy Players. All players who attend for treatment by the Acadmey therapists must be accompanied by a parent/guardian.
I hereby give consent for the player named above to be assessed and treated by the West Bromwich Albion FC medical staff. In the event of emergency, I agree to medical treatment being given to my son if required, including administration of general anaesthetic and to surgical operations in the case of emergency accordance with the recommendatin of a qualified medical practitioner.
Please select age group