ROBLIN MINOR HOCKEY

PLAYER MEDICAL INFORMATION SHEET

2016/2017 SEASON

Player Information

Name ________________________________________________________________________

Date of Birth: Day ________ Month _________ Year ________

Address _______________________________________________________________________

Personal Medical Number (9 digit number) ____________________________________________

Family Medical Number (6 digit number) ______________________________________________

Parent/Guardian Information

Mother/Guardian Father/Guardian

Name _______________________________________ Name __________________________________

Address _____________________________________ Address ________________________________

Home Phone _________________________________ Home Phone ____________________________

Cell Phone ___________________________________ Cell Phone ______________________________

E-mail Address ________________________________ E-Mail Address ___________________________

Alternate Contact Information

Person to contact in case of emergency if parents are not available:

Name: _________________________________ Address: ___________________________________________

Home Phone: ____________________________ Cell Phone: _________________________________________

Doctors Name: __________________________ Phone: _____________________________________________

Dentist Name: ___________________________ Phone: _____________________________________________

Medical Information
The following information will be provided to the coaching staff. Coaches will use this information to effectively
coach and assist your child with any medical challenges throughout the season.

Please circle the appropriate response below pertaining to your child:

Yes No Previous History of Concussions

Yes No Fainting Episodes During Exercise
Yes No Epileptic
Yes No Wears Glasses
Yes No Are Lenses Shatterproof
Yes No Wears Contact Lenses
Yes No Wears Dental Appliance
Yes No Hearing Problem
Yes No Asthma
Yes No Trouble Breathing During Exercise
Yes No Heart Condition
Yes No Diabetic
Yes No Wears A Medic Alert Bracelet
Yes No Surgery In The Last Year
Yes No Any Injuries Requiring Medical Attention In The Last Year
Yes No Has Had A Hospital Stay In The Last Year
Yes No Presently Injured

Please give details below if you have answered yes to any of the above items:

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

Medications: _______________________________________________________________________________

Allergies: __________________________________________________________________________________

Medical Conditions: __________________________________________________________________________

Recent Injuries: _____________________________________________________________________________

Any Child Developmental Concerns (ADHD, Autism, etc.): ___________________________________________

__________________________________________________________________________________________

Any Information Not Covered Above: ____________________________________________________________

__________________________________________________________________________________________

Before participating in a hockey program, all medical conditions or injury concerns should be checked by your
physician. If a player has been unable to participate in minor hockey activities due to injuries or medical conditions,
a physicians note may be required in order for player to resume any on-ice activities.

I understand that it is my responsibility to keep the team coaches and mangers advised of any change in the above
information as soon as possible, and that in the event no one can be contacted, team management will take my
child to the hospital 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 the appropriate people (coach, physician) as deemed necessary.

Dated this day of , 201 .

Signed
Name of Parent/Guardian __________________________________________________