Date
of Birth:Day______Month________Year________
Address:_______________________________________________
Postal
Code:___________Telephone:_____________
Mother’s
Name:_____________Father’s
Name:______________
Business
Telephone Numbers: Mother___________Father___________
Person
to contact in case of accident or emergency, if parents are not available:
Name:___________________Relationship:__________________
Address:__________________________Tele
#:_________________
Doctor’s
Name:____________________________Tele
#:_________________
Dentist’s
Name:____________________________Tele
#:_________________
Please
circle the appropriate response below pertaining to your child:
Previous
history of concussions
Yes
No Fainting episodes during exercise
Yes
No Epileptic
Yes
No Wears glasses
Yes
No Are lenses shatterproof?
Yes
No Wears contact lenses
Yes
No Wears dental appliance
Yes
No Hearing problem
Yes
No Asthma
Yes
No Trouble breathing during exercise
Yes
No Heart condition
Yes
No Diabetic
Yes
No Has had an illness lasting more than a week
in the past year
Yes
No Medication
Yes
No Allergies
Yes
No Wears a medic alert bracelet or necklace
Yes
No Does your child have any health problem that
would interfere with
Participation
on a hockey team?
Yes
No Surgery in the last year
Yes
No Hospitalized in the last year
Yes
No Injuries requiring medical attention in the
last year
Yes
No Presently injured
If
you answered “Yes” to any of the above items, please provide details below
(Use separate sheet, if necessary):
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Medications:________________________________________________________________
Allergies:________________________________________________________________
Medical
Conditions: _____________________________________________________________
Recent
Injuries:________________________________________________________________
Last
Tetanus Shot: ______________________________________________________________
Any
information not covered above:
_____________________________________________________________________________
_____________________________________________________________________________
Date
of last complete Physician examination:______________________________________
Any
medical condition or injury problem should be checked by your physician
before participating in a hockey program.
I
understand that it is my responsibility to keep the team management advised
of any change in the above information as soon as possible and that in
the event no one can be contacted, team management will take my child to
hospital/M.D. if deemed necessary.
I
hereby authorize the Physician and nursing staff to undertake examination,
investigation and necessary treatment of my child.
I
also authorize release of information to appropriate people (Coach, Physician,
Trainer, and Manager) as deemed necessary.
Signature
of Parent or Guardian:___________________________Date:______________