Medical Form

Player Full Name

Birthdate

Parent/Guardian Phone Number

Alberta Health Care Number

Parent/Guardian Name(s)

Alternative Parent/Guardian Phone Number

Emergency Contact (if Parent/Guardian unavailable)

Emergency Contact Phone Number

Family Physician

Physician Phone Number

Record of illness(es) or condition(s), past or present, that may affect or be affected by performance (Please list all)

Specify any other issues, injuries, or surgeries that may affect or be affected by performance (ex. headaches, blackouts, fractures, concussions, etc.)

Does the player wear glasses or contact lenses?

Immunization: Year of last Tetanus Shot

List all allergies and medications taken regularly

Player Division Mini Tyke Tyke Novice Peewee Bantam Midget

Date Medical History Completed

Name of person who completed this medical history & relation to player.

Submit