Liverpool Schools FA Confidential Information and Medical Form Last Name   First Name   Date of Birth (Day, Month, Year)   Any Family Information You Feel We Should Be Aware Of.   Parents' Names   Home Address   Home Phone   Mobile Numbers (state mum's or dad's).   Work/Daytime Numbers   Contact email   Emergency Contact and Phone   School   School Phone   GP Name and Address & Phone   Medical Conditions and Associated Medication   Allergies   Any Relevant Previous Injuries   Date of Last Tetanus   Any Other Medical Information You Feel We May Need to Know   Consent I authorise the staff of the LSFA to act on my behalf in case of medical emergency. This may include the rendering of first aid or a member of staff giving consent, in the absence of the child’s parents, to treatment, which in the opinion of a qualified medical practitioner may be necessary for my child. Name (Please Print)   Signed   Date