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Hockey Canada Player Medical Form

 
Name *
Name
Birthdate *
Birthdate
Address *
Address
Telephone *
Telephone
Cell Phone *
Cell Phone
(optional)
Section
Parent/Guardian #1 Name *
Parent/Guardian #1 Name
Phone Number *
Phone Number
Parent/Guardian #2 Name
Parent/Guardian #2 Name
Phone Number
Phone Number
Alternative Emergency Contact
Emergency Contact Name
Emergency Contact Name
if parents are not available
Telephone
Telephone
Cell
Cell
Doctor's Name *
Doctor's Name
Telephone *
Telephone
Dentist Name *
Dentist Name
Telephone *
Telephone
Date of last complete physical examination *
Date of last complete physical examination
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
Please check the appropriate response and provide details below if you answer “Yes” to any of the questions. *
Date of last tetanus shot *
Date of last tetanus shot
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.
Player Name *
Player Name
Date
Date
By checking this box I agree to the conditions outlined above. *
Parent/Guardian *
Parent/Guardian
Date
Date
By checking this box I agree to the conditions outlined above. *
Disclaimer: Personal information used, disclosed, secured or retained by Hockey Canada will be held solely for the purposes 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.