Medical Form

Your Name *

Your Email *

Player Information

Name *

Please provide first & Last Name

Date of Birth *

Gender *

Home Address *

Please provide players address including town & postal code

Cell number

If applicable

Alberta Health Care Number *

Parent/Guardian Information

Parent/Guardian 1

Name *

Please provide first & Last Name

E-mail *

Home address

If different from player's

Relationship to player *

Emergency Contact Information

Parent/Guardian will be called 1st

Parent/Guardian 2

Name *

Please provide first & last name

E-mail *

Phone Number *

Phone Number *

Secondary Phone Number

Secondary Phone Number

Home Address

If different from player's

Relationship to player *

Family Doctor & Phone Number *

Please provide Dr name & Phone number

Dentist Name & Phone Number *

Medical Information

Please check box if condition applies

History of concussions

Yes

Fainting episodes during exercise

Yes

Epileptic

Yes

Wears glasses

Yes

Wears contact lenses

Yes

Wears dental applicance

Yes

Hearing problems [hearing aids]

Yes

Asthma

Yes

Trouble breathing during exercise

Yes

Heart Condition

Yes

Diabetic

Yes

Has had a serious illness in the last 12 months

Yes

Is on medication

Yes

Wears a medic alert bracelet or necklace

Yes

Does the player have a health problem, which would interfere with physical exercise

Yes

Any surgeries in the last 12 months

Yes

Has been hospitalized in the last 12 months

Yes

Has had injuries in the last 12 months requiring medical attention

Yes

Presently injured

Yes

Please verify that you are a human.