Medical Information Sheet (Ancaster Minor Hockey)

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Name & Address

Name:

Date of birth:

Open the calendar popup.

Address:
Postal Code
Telephone:
Cell #:
Name of Parent/Guardian #1:
Business phone number:
Name of Parent/Guardian #2:
Business phone number:

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.

Name
Relationship to player:
Telephone:
Cell:
Doctor's Name:
Telephone:
Dentist's Name:
Telephone:
Date of last complete physical examination:

Medical History

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

Medication^*
YesNo
Allergies^*
YesNo
Previous history of concussions^*
YesNo
Fainting or seizure during or after physical activity^*
YesNo
Near fainting or Brownouts^*
YesNo
Seizures and/or epilepsy^*
YesNo
Wears glasses^*
YesNo
Are lenses shatterproof?^*
YesNo
Wears contact lenses^*
YesNo
Wears dental appliance^*
YesNo
Hearing problem^*
YesNo
Asthma^*
YesNo
Trouble breathing during exercise^*
YesNo
Heart condition^*
YesNo
Palpitations or Racing Heart^*
YesNo
Family history of heart disease^*
YesNo
Family history of unexpected death during physical activity^*
YesNo
Family history of unexplained death of a young person^*
YesNo
Diabetes - Type 1^*
YesNo
Diabetes - Type 2^*
YesNo
Wears medical information bracelet/necklace?^*
YesNo
If yes to above, for what purpose?
Health problem that would interfere with participation on a hockey team^*
YesNo
Has had an illness that lasted more than a week and required medical attention in the past year^*
YesNo
Has had injuries requiring medical attention in the last year^*
YesNo
Been admitted to hospital in the last year^*
YesNo
Surgery in the last year^*
YesNo
Presently injured^*
YesNo
If yes to above, injured body part
Vaccinations up to date^*
YesNo
Date of last Tetanus Shot:^*
Hepatitis B vaccination^*
YesNo

Details

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

Use separate sheet if necessary
Medication
Allergies
Medical conditions
Recent injuries
Any information not covered by above

Signatures

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.

Signature of Player^*
Date^*
Signature of Parent or Guardian:^*
Date:^*

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.

Human Validation

Check The Box ^*

Medical Information Sheet (Ancaster Minor Hockey)

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