Registration - Player Medical Form
Player Medical Form

Please be accurate with all information provided

Name
Address
City, Province, Postal Code:
Phone
Email
Confirm Email
Emergency Contact Name 1:
Emergency Contact Name 2:
Emergency Contact Number 1:
Emergency Contact Number 2:
Provincial Health Number
Height
Weight
Date of Birth (M/D/YYYY)
Previous Known Medical Conditions
Previous History of Concussions
Previous History of Fainting
Epileptic
Asthma
Heart Condition
Diabetic
Allergies
Current Medical Concerns
Please add all relevant information in this comment area:
Any medical condition or injury problem should be checked by your physician before participating in a hockey program.

I understand that it is my responsibility to keep the team management advised of any change in the above information as soon as possible and that in the event no one can be contacted, team management will take my child to hospital/MD if deemed necessary.

I hereby authorize the physician and training staff to undertake examination, investigation and necessary treatment of my child.

I also authorized release of information to appropriate people (coach, physician) as deemed necessary.
Name
Date
I acknowledge that everything listed above is true and accurate to the best of my understanding and accept the above conditions
Comments