North Toronto Soccer Medical Form

North Toronto Soccer Medical Form

Player Name

First NameLast Name

Date of Birth (MM/DD/YYYY)

Date

PARENT/CAREGIVER CONTACT INFORMATION

ParentCaregivers full name

Phone number

Alternate phone number

EMERGENCY CONTACT NUMBERS (other then parent/caregiver above)

Full name and relationship to the child

Phone number

Alternate phone number

CHILD INFORMATION: Please share the following information regarding your child (indicate N/A for those that do not apply):

Allergies

Does the player have an Epipen?

YesNo

Medical Conditions

Behavioral Concerns

Other conditions

EMERGENCY MEDICAL RELEASE

I certify that my child, First Name Last Name, is healthy and free of problems that could be deleterious to his / her participation in the North Toronto Soccer Club (NTSC) PA Day, March Break, Summer Camp or Academy. In case of injury, I wish to be contacted as soon as possible at the telephone number listed above. If I cannot be reached, please contact the emergency number that I have listed above.

I also give NTSC permission to treat my child in the event of an emergency if I or the emergency contact cannot be contacted. In the event of serious illness or injury, and so that my child may be sent to the local hospital via ambulance, I understand that I am responsible for all charges, either through health insurance or otherwise.

Initial

Primary Care Physician

Phone Number

PICK UP AUTHORIZATION

In addition to primary caretakers listed on this form, I authorize the following individuals to pick up my child from NTSC.

1. Name and relationship to the child

2. Name and relationship to the child

SELF SIGN-IN AND SIGN-OUT

Is this child allowed to sign themselves in and out and leave on their own

YesNo

SIGNATURE

DATE

Date