Name
First Name
Last Name
Team Name
Address
City
Province
Date of Birth
*
Health Care
Family Dr
Phone #
Format: (000) 000-0000.
Emergency Contact Name
Phone #
Format: (000) 000-0000.
Relationship
Allergies
Medications
Other medical history that you think may be relevant to the coaching staff
Parent Signature
Date
/
Month
/
Day
Year
Date
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