Medical Information Sheet (Ancaster Minor Hockey)

Medical Information Sheet

Name & Address

Alternate emergency contact (if parents are not available)

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.

Medical History

Plesae check the appropriate responses and provide details below if you answer "Yes" to any of the questions.


Please give details if you answered "Yes" to any of the above


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 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.

Disclaimer: Personal information used, disclosed, secured or retained by Hockey Canada will be held solely for the purpose for which we collected it and in accordance with the National Privacy Principles contained in the Personal Information Protection and Electronic Documents Act as well as Hockey Canada's own Privacy Policy.