Medical Information Form 2026-27

Medical Information Form 2026-27

Before a player participates in a hockey program, it is recommended that they have a medical and that they also have any medical condition or injury problem checked by their family physician.
Basic Information
Athlete's Name

First NameLast Name
Date of birth

MonthDayYear
Date
Emergency Cell Phone 1
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Cell Phone 2
MUST BE DIFFERENT THAN CELL #1.Format: (000) 000-0000.
Email
example@example.com
Division
If you are trying out for the 'A' program, please select that option for your division.
Personal Health Number
Do not type any spaces.
Doctor's Name
Doctor's Phone
Please enter a valid phone number.Format: (000) 000-0000.
Health Information
Medical Conditions (Check all that apply. If none apply, choose that option at the bottom)
If you checked off any of these conditions, please elaborate below. If no conditions were checked, please use N/A.
Use N/A if nothing to add
If athlete wears a medical bracelet, which condition?
Use N/A if no bracelet
If presently injured, which body part?
Use N/A if not injured
Standard Vaccinations up to date?
Date of last Tetanus shot. If you don't know the exact date, please choose the first day of the month, and the year, it was last given. If your child has never had a Tetanus shot, please use the date Jan 1, 2000.

MonthDayYear
Date
Concussion History
Please provide details on any learning or behavioural challenges. If there are no challenges to report, please use N/A.
Acknowledgement

I understand that it is my responsibility to keep the HCSP advised of any change in the above information as soon as possible. In the event of a medical emergency and that no one can be contacted, team management will arrange to take my child to the hospital or a physician 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) as deemed necessary.
Guardian's Full Name

First NameLast Name
Signature
Should be Empty:

Medical Information Form 2026-27

Basic Information

Health Information

Acknowledgement