11/09                                                                                                                                                                   

                                                                                                                                                                          “Kick Off” 

GENERAL DISCLAIMER

I, …………………………………………………………….……….(PRINT NAME IN FULL)

on this date…………………………………………….have refused to…………………………………

…………………………………………………………………………………………………………….

…………………………………………………………………………………………………………….

……………………………………….........................................................................................................

……………………..as advised, recommended, suggested &/or referred by the       .....         Program Director

                                                                                                                                                .....         Senior Clinician

                                                                                                                                                .....           Psychiatrist

                                                                                                                                                .....            Psychologist 

                                                                                                                                                .....            GP 

I understand that by refusing to …………………………………………………………………………

…………………………………………………………………………………………………………...

……………………………I may compromise or jeopardize my wellbeing & any efficacy of treatment.

I also understand that this refusal will be noted & documented in my ‘confidential’ personal file for future reference.

I understand by refusing and the signing of this document, the responsibility rests solely with me and not the organisation or the staff of ‘Kick Off’.

I make this refusal and sign this document with full understanding of its implications and by way of sound and unimpaired judgment, having been fully informed of that to which I have refused.

Signed at……………………………………………..    this     ……………………..day of

…………………………………………….20………..

SIGNED………………………………………PRINT NAME………………………………………………

WITNESSED…………………………………PRINT NAME………………………………………………                                                                                                                                                                                                     

                                                                                                               Client Identifier…………………..

Client Consent To The Release Of Information

I ……………………………………………………………………………………………

                                                                (please print)

am aware of, and understand the need for sharing my personal information and health history to ensure

that I receive the best possible level of treatment and/or care. My rights in this issue have been explained

fully to me by……………………………………………................................................................................

............................................................................................. (name & role within the ‘Kick Off’ organisation)

I hereby give my informed consent for ‘Kick Off’ to release/request/provide relevant information to/from the following organisations or individuals:

General Practitioner (GP)/Medical Specialist                                          Yes….                   No….

Psychiatrist                                                                                                      Yes….                   No….

Psychologist                                                                                                     Yes….                    No….

New South WalesHealth Service Provider                                                 Yes….                    No…. 

QueenslandHealth Service Provider                                                           Yes….                     No….

Victorian Health Service Provider                                                               Yes….                   No….

New ZealandHealth Service Provider                                                          Yes….                     No….

Other……………………………………………………                            Yes….                   No….

          ……………………………………………………

I specifically request that no information regarding to me be given to the following individuals/clubs/organisations:

                ……………………………………………………………………………………………………

                ……………………………………………………………………………………………………

Client’ signature………………………Date………Witness’ signature…………………………Date………

                Name & designation of Witness: ………………………………………………………………...

I do not/no longer give my consent to sharing my personal information &/or health history

Client Signature………………………Date……...... Witness’ Signature………………………Date………

   11/09

“Kick Off”

Player Personality Profile Consent

I,…………………………………………………………………………(PLEASE PRINT FULL NAME)

hereby give my full consent to the undertaking of this assessment, having been fully explained the reasons

for the assessment and my associated rights in respect to the gathering of this information.

My rights and the information relating to details of the Player Personality Profile (PPP) assessment tool

have been explained to me by………………………………………………………………......................

                                                              (name & designation of ‘Kick Off’ representative)

______________________________________________________________________________________

I understand and give my consent to this information being stored within a personal ‘confidential’ file held

by the ‘Kick Off’ organisation.

Signed at……………………………………………..    this     ……………………..day of

…………………………………………….20………..

SIGNED………………………………………PRINT NAME………………………………………………

WITNESSED…………………………………PRINT NAME………………………………………………                                                                                                                                                                                                     

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                                                                                                                                                               11/09

“Kick Off”

‘Kick Off’ staff confidentiality contract

I, …………………………………………………………………………… (PRINT FULL NAME)

being employed/engaged by the ‘Kick Off’ organisation in the capacity of …………………………………

…………………………………………………………………………………………………………………

Hereby guarantee to uphold the ‘Mission Statement’ of the organisation and adhere to its ‘Core Values’ and

‘Code of Conduct’. 

______________________________________________________________________________________

I will, at all times, maintain the privacy and confidentiality of the client of the service and will not disclose

any information or personal details of clients or those who may make contact with the organisation.

I have been given a copy of the ‘Mission Statement’, ‘Core Values’ and ‘Code of Conduct’ and explained

the necessary privacy requirements of the ‘Kick Off’ program and service by

………………………………………………………………………………………….(name & designation)

______________________________________________________________________________________

I further agree that violation of any of the essential requirements of the organisation in relation to privacy &

confidentiality may result in the immediate termination of my employment with ‘Kick Off’.

SIGNED………………………………………… this ……………day of …………………….. 20…….

WITNESS…………………………………………

FULL NAME…………………………………………..

DESIGNATION/JOB TITLE…………………………………………………………………..

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   11/09

“Kick Off”

Consent to Contact

I, ………………………………………………………………………(PLEASE PRINT FULL NAME)

hereby permit and give my consent for the ‘Kick Off’ team and/or its appointed representative,

…………………………………………………………(NAME & DESIGNATION), to make contact with

the following individuals……………………………………………………………………………………..

…………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………

for the purpose of providing essential information to these individuals in relation to my health. I have been

fully explained the reasons for this need by…………………………………………………………………..

                                                                                                            (name & designation)

______________________________________________________________________________________

I further understand and give consent for these individuals to provide information to the ‘Kick Off’ team

&/or its appointed representative…………………………………………………………………………….

                                                                                                      (name & designation)

 SIGNED…………………………..………………………… this………………..day…………………….

WITNESS…………………………………………….. NAME …………………………………………….

______________________________________________________________________________________

I do not/no longer give my consent to sharing my personal information &/or health history to (1) ALL the individuals noted above (2) those noted through alteration by my own hand, and initialed & witnessed.

Client Signature………………………Date……......

Witness’ Signature………………………Date………..

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