Med Form 2
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- Pages: 1
Yes
No
Hasany healthproblemthat would interferewith participationon a hockeyteam
Yes
No
Yes
No
Has hadan illnessthat lastedmore than a week and requiredmedicalattention in the Pastyear Has had injuriesrequiringmedicalattentionin the pastyear
Yes
No
Has beenadmittedto hospitalin the lastyear
Yes
No
Surgeryin the lastyear
Yes
No
Presentlyinjured. Injuredbody part:
Yes
No
Vaccinations up to date Date of lastTetanus Shor_
Yes
No
HepatitisB vaccination
Pleasegive details if you answered "Yes' to any of the above. Use separate sheet if necessary
Allergies: Medicalconditions: Recentinjuries: Any informationnot covered above: I understand that it is my responsibilityto keepthe team HockeyTraineradvisedof anychangein the above informationas soon as possible.In the eventof a medicalemergencyand that no one can be contacted,team management will arrangeto take my child to the hospitalor a physicianif deemednecessary. I herebyauthorizethe physicianand nursingstaffto undertakeexamination, investigation and necessarytreatmentof my child. I alsoauthorizereleaseof informationto appropriatepeople(coach,physician) as deemednecessary.
Date:
Signatureof Parentor Guardian:
Disclaimer:Personalinformation used,disclosed,secured or retained will be held solely for the purposesfor which it is collected and in accordancewith the National PrivacyPrinciplescontained in the PersonalInformation Protection and Electronic DocumentsAct.
HocKEY
T RA IN E RS
CE R TIFIGATIoN
PRoGRAM
No
Hasany healthproblemthat would interferewith participationon a hockeyteam
Yes
No
Yes
No
Has hadan illnessthat lastedmore than a week and requiredmedicalattention in the Pastyear Has had injuriesrequiringmedicalattentionin the pastyear
Yes
No
Has beenadmittedto hospitalin the lastyear
Yes
No
Surgeryin the lastyear
Yes
No
Presentlyinjured. Injuredbody part:
Yes
No
Vaccinations up to date Date of lastTetanus Shor_
Yes
No
HepatitisB vaccination
Pleasegive details if you answered "Yes' to any of the above. Use separate sheet if necessary
Allergies: Medicalconditions: Recentinjuries: Any informationnot covered above: I understand that it is my responsibilityto keepthe team HockeyTraineradvisedof anychangein the above informationas soon as possible.In the eventof a medicalemergencyand that no one can be contacted,team management will arrangeto take my child to the hospitalor a physicianif deemednecessary. I herebyauthorizethe physicianand nursingstaffto undertakeexamination, investigation and necessarytreatmentof my child. I alsoauthorizereleaseof informationto appropriatepeople(coach,physician) as deemednecessary.
Date:
Signatureof Parentor Guardian:
Disclaimer:Personalinformation used,disclosed,secured or retained will be held solely for the purposesfor which it is collected and in accordancewith the National PrivacyPrinciplescontained in the PersonalInformation Protection and Electronic DocumentsAct.
HocKEY
T RA IN E RS
CE R TIFIGATIoN
PRoGRAM
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