2024-25 PLAYER MEDICAL INFORMATION FORM

PLAYER INFORMATION

Player's First Name *

Player's Last Name *

Date of Birth * +

Father's Name *

Cell Phone

Mother's Name *

Cell Phone

EMERGENCY CONTACT (if parent/guardian is unavailable)

Emergency Contact *

Phone Number *

Relationship *

MEDICAL INFORMATION

Provincial Health Number *

Doctor's Name *

Phone Number

Provide detail for any allergies, illnesses, disabilities, medical conditions, or recent surgeries: *

List any medications taken regularly: *

I understand that it is my responsibility to keep the Coach and/or Association advised of any change in the above information as soon as possible. Also, in the event of an emergency, if no one can be contacted, Team Management will take my child to the hospital/doctor if deemed necessary.

I hereby authorize the physician and nursing staff to undertake examination, investigation, and necessary treatment of my child.

I also authorize the release of information to the appropriate people (Coach, Physician) as deemed necessary.

Signed by the Participant or, if under the age of 19, the Legal Guardian:

Please type name: *

Please sign here: *

clear

Date Signed * +

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