PRIVATE AND CONFIDENTIAL
Player Details
These details are for you, the player, which will be used by the County medical team. Due to the declaration required at the end of this form, these details MUST be those of the person completing the form.
Emergency Contact
This person will be the first person contacted in the event of an emergency, please ensure you choose someone who is accessible at all times.
Player's Doctor
These details are for the player's doctor, who on occasion, may need to be contacted by the County medical team.
Medical History
Do you have any medical conditions, allergies or injuries (previous or current)?
Cardiac History
This section is required for completion, if no previous cardiac screening has been done.
If the answer is YES to any of the above Cardiac History questions, you must obtain clearance from your NHS General Practitioner, confirming that you are fit to undertake physical activity. These questions are used as a simple screen and do not necessarily mean that there is a cardiac problem, but do give an indication that requires possible follow up by a doctor.
Declaration and Consent
IT IS IMPORTANT THAT YOU READ AND ACCEPT ALL OF THE FOLLOWING PARAGRAPHS. IF YOU ARE UNSURE OF ANYTHING OR HAVE ANY QUERIES PLEASE CONTACT US. By clicking the 'Submit' button below you are agreeing to the following:
- I hereby authorise any of the Surrey County Team Management or Medical Team Members, to sign any necessary consent form(s) in respect of any treatment or anaesthetic, which may be required during my involvement with the Surrey Rugby Mens XV County Squad Programme.
- I consent to the processing of my personal and medical data, and I understand that the Surrey County Team Management or Medical Team Members may share and obtain personal and medical information with other parties for the purposes of player welfare or when assessing fitness to play.
- I agree to relevant details from consultations, tests or treatments undertaken by our medical team being released to coaches, members of support staff, and any other third party responsible for your welfare.
- I understand that by not signing up to ‘Return to Play’ I will not be formally assessed by one of the qualified ‘Return to Play’ doctors should I get injured or have concussion symptoms. Therefore, I may not be able to participate in Surrey County rugby without satisfactory completion of a graduated return to play protocol and a written doctor’s certificate or note.
- By signing below, I consent to the Surrey medical team processing and obtaining medical information about me so that they can assess my fitness to play. I also consent to Surrey County Team Management or Medical Team Members sharing and obtaining information with other parties responsible for your care or welfare.
- By clicking the 'Submit' button below you agree with Surrey Rugby Policy - Representative Rugby: Injuries, Insurance & Support Ref 12/2025. Download and read Policy
