NLBA Medical Waiver

Form Name

Program Name

AcademyCanada GamesU14 Male Provincial ProgramU14 Female Provincial ProgramU15 Male Provincial ProgramU15 Female Provincial ProgramU16 Male Provincial ProgramU16 Female Provincial ProgramU17 Male Provincial ProgramU17 Female Provincial Program

Full Name of Child

First NameLast Name

Email

example@example.com

Gender

MaleFemaieOther

Healthcare Card #:

MCP #:

MCP Expiry Date:

Date

Name of Parent/Guardian

First NameLast Name

Parent/Guardian Phone

Area CodePhone Number

Emergency Contact Name:

First NameLast Name

Emergency Contact Phone:

Area CodePhone Number

Please indicate ANY and ALL current medical conditions:

Please indicate all prescriptions that you are taking: (prescribed and non-prescription, whether taken occassionally or on a regular basis)

Please indicate if food sensitivities or dietary requirements: (i.e food allergies/sensitivities, vegan, vegetarian, etc.)

Consent to Emergency Medical Treatment & Release of Medical Records

I hereby consent to and authorize emergency medical and/or dental treatment during my son or daughter’s involvement in the 2020 – 2021 Academy Program or such period reasonably related thereto.
I hereby consent to the release of medical information to NLBA in event of injury or other medical emergency.
I hereby acknowledge that no treatment or procedure referred to above will be administered except with the consent by myself or appropriate substitute decision make in accordance with appropriate legislation and with the same limitations and conditions contained therein
I hereby confirm that this is not a power of attorney for personal care.

Parent/Guardian Signature

Date