Parkinson's Walking Football

Medical Information

Allergies and Medication
Does the participant suffer from any allergies?*

YesNo
If yes, please give details
Is the participant taking any medication?*

YesNo
If yes, please list here
Is there any other relevant information that may affect any treatment in an emergency?
Doctor's Name
Doctor's Telephone Number

Consent
Photos and videos of you may be taken at the Activity (the Images).The Foundation would like to use the Images to promote the work of the Foundation and grant Chelsea Football Club the right to do the same. This use may include print advertising, digital advertising and/or inclusion in presentations to partners, funders and other charitable organisations the Foundation works with or wishes to work with.*

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Parkinson's Walking Football - Sign Up Form