Wildcats Bantam (U15) > U15-B #6883 > Medical Form (Woodstock Wildcats)

Medical Form

OWHA Medical Form

Medical Information Sheet

Please complete for each of your players

Full Name:^*

Required

Date of Birth:^*

Required

Please use this format: Day-Month-Year ie. 01JAN2012

Address^*

Required

Full mailing address, include postal code

Home Phone Number:

Cell Number:^*

Required

Health Card Number:^*

Required

Parent/Guardian #1

Name:^*

Required

Email address:^*

Required

Example: [email protected]

Phone Number:^*

Required

Relationship to Player:^*

Required

Parent/Guardian #2

Name:

Email address:

Example: [email protected]

Phone Number:

Relationship to Player:

Alternate emergency contact (if parents/guardians are not available)

Name:^*

Required

Relationship to Player: ^*

Required

Home Phone Number:

Cell Number: ^*

Required

Doctor & Dentist information

Doctor's Name:^*

Required

Doctor's Telephone Number:^*

Required

Dentist's Name:^*

Required

Dentist's Telephone Number:^*

Required

Medical Questionnaire

Please indicate 'yes' or 'no'. If you answer 'Yes' to any question, please provide more details in the next section below.

Medication^*

Required

Allergies^*

Required

Previous history of concussions^*

Required

Fainting or seizure during or after physical activity^*

Required

Near fainting or Brownouts^*

Required

Seizures and/or Epilepsy^*

Required

Wears glasses^*

Required

If yes to wears glasses, are lenses shatterproof

Wears contact lenses^*

Required

Wears dental appliance^*

Required

Hearing problem^*

Required

Asthma^*

Required

Trouble breathing during exercise^*

Required

Heart Condition^*

Required

Palpitations or Racing Heart^*

Required

Family history of heart disease^*

Required

Family history of unexpected death during physical activity^*

Required

Family history of unexplained death of a young person^*

Required

Diabetes - Type 1^*

Required

Diabetes - Type 2^*

Required

Wears medical information bracelet/necklace^*

Required

If yes to wears medical information bracelet/necklace, for what purpose?

Health problem that would interfere with participation on a hockey team^*

Required

Has had an illness that lasted more than a week and required medical attention in the past year^*

Required

Has had injuries requiring medical attention in the past year^*

Required

Been admitted to hospital in the last year^*

Required

Surgery in the last year^*

Required

Presently injured^*

Required

If yes to presently injured, indicate Injured body part:

Vaccinations up to date^*

Required

Date of last Tetanus Shot: ^*

Required

Hepatitis B Vaccination^*

Required

Additional Information

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

Medications:

Allergies:

Medical Conditions:

Recent Injuries:

Any information not covered 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.

I agree to the terms and conditions stated above^*

Signature

Date:^*

Required

Signature:^*

Required

Typed signature of parent/guardian if player is under the age of 18

Medical Form, U15-B #6883, Wildcats Bantam (U15) (Woodstock Wildcats)

Medical Information Sheet

Parent/Guardian #1

Parent/Guardian #2

Alternate emergency contact (if parents/guardians are not available)

Doctor & Dentist information

Medical Questionnaire

Additional Information

Signature

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