Medical Information Form 2023-24
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 Name
Last Name
Emergency Cell Phone 1
*
Please enter a valid phone number.
Emergency Cell Phone 2
*
MUST BE DIFFERENT THAN CELL #1.
Email
*
example@example.com
Division
*
Please Select
U6
U7
U8
U9
U11 A
U11 C
U13 A
U13 C
U15 A
U15 C
U18 A
U18 C
U21 A/C
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.
Health Information
Medical Conditions (Check all that apply. If none apply, choose that option at the bottom)
*
Medication
Allergies
Previous history of concussions
Fainting or seizure during or after physical activity
Near fainting or Brownouts
Seizures and/or epilepsy
Wears glasses
Are lenses shatterproof
Wears contact lenses
Wears dental appliance
Hearing problem
Asthma
Trouble breathing during exercise
Heart Condition
Palpitations or Racing Heart
Family history of heart disease
Family history of unexpected death during physical activity
Family history of unexplained death of a young person
Diabetes Type 1
Diabetes Type 2
Has had an illness that lasted more than a week and required medical attention in the past year
Has had injuries requiring medical attention in the past year
Been admitted to hospital in the last year
Surgery in the last year
Health problem that would interfere with participation on a hockey team
NONE OF THESE APPLY
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?
*
Yes
No
Rather not say
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.
*
-
Month
-
Day
Year
Date
Concussion History
*
No diagnosed concussions
1-2 diagnosed concussions
3+ diagnosed concussions
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 Name
Last Name
Signature
*
Clear
Submit
Should be Empty: