FSMH Medical Information Sheet

FSMH Medical Information Sheet
This information will be use by the Team Safety. This will help the Safety Person assist players should they become ill or injured. This form also authorizes them to seek emergency medical attention for a player if they are injured in a practice/game and their parent/guardian isn't present or can't be reached. Complete this form with all the details that match your child's medical file.
Player Name*

First NameLast Name
Date of Birth*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityProvince

Postal Code
Players Hockey Canada Division
Provincial Health Care Number
(Optional)

Parent/Guardian & Emergency Contact Information
Parent/Guardian #1*

First NameLast Name
Cell Phone Number
Parent/Guardian #2:

First NameLast Name
Cell Phone Number
Alternate Emergency Contact (If parents/guardians are not available)*

First NameLast Name
Relationship to Player:*
Telephone *

Area CodePhone Number

Medications:
If none, enter N/A
Allergies:
If none, enter N/A
Recent Injuries:
If none, enter N/A
Any Information not covered above:
If none, enter N/A
I understand that it is my responsibility to keep the team Safety Person 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/Safety 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.
Date:*

MonthDayYear
Date
Parents full name:

First NameLast Name
Email
example@example.com
Signature of Parent or Guardian:*

Clear
By signing you agree to the conditions stated above
Should be Empty:

	Yes	No
Previous history of concussions
Fainting or seizure during or afterphysical activity
Near fainting or Brownouts
Epileptic
Wear glasses
Are lenses shatterproof
Wears contact lenses
Wears dental appliance
Hearing problem
Asthma
Trouble breathing during exercise
Heart Condition
Medication
Allergies
Has any health problem that would interfere with participation on a hockey team
Has an illness that lasted more that a week and required medical attention in the past year
Has had injuries requiring medical attention in the past year
Has been admitted to hospital in the last year
Surgery in the last year
Hepatitis B vaccination

Parent/Guardian & Emergency Contact Information