Raiders Medical Form

Player Name

Sweater #

Date of Birth

Provincial Health Number (optional)

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Player Email

Player Phone Number

Player Cell Number

Mother's Name

Mother's Daytime Phone Number

Mother's Cell Number

Father's Name

Father's Daytime Phone Number

Father's Cell Number

Emergency Contact Name

Emergency Contact Number

Emergency Contact Relation to Player

Billet Name (if applicable)

Billet Number (if applicable)

Doctor's Name

Doctor's Contact Number

Dentist's Name

Dentist's Contact Number

Please check the appropriate box for any question you would respond "YES" to. Provide additional details in the box below for any checked checkbox.

Have you ever fainted while exercising?Are you Epileptic?Do you wear glasses?Are your lenses shatterproof?Do you wear contact lenses?Do you wear a dental appliance?Do you have a hearing problem?Do you have Asthma?Do you have an Asthma puffer?Do you have trouble breathing during exercise?Do you have any known Heart condition?Are you a Diabetic? Type 1 or 2Do you have an insulin pump?Have you had an illness lasting more than a week in the past year?Do you take any Medication?Do you have any Allergies?Do you wear a medic alert bracelet or necklace?Do you have any health problem that would interfere with participation on a hockey team?Have you had Surgery in the last year?Have you been in hospital in the last year?Have you been to a doctor in the last year?Have you had injuries requiring medical attention in the past year?Are you Currently injured?

If you've answered yes to any of the questions above please provide additional details here.
Please list all allergies. If you have any family medical history concerns please list them here as
well.

Please enter any relevant information not covered above here.

Date of last tetanus shot

Date of last complete physical exam

Note: Any medical condition or injury should be checked by your physician before participating in a
hockey program.

I have thoroughly read all questions on this page and answered them to the best of my knowledge. I understand that it is my responsibility to keep the team management 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 this player to hospital/M.D. if deemed necessary. I hereby authorize the physician and nursing staff to undertake examination, investigation and necessary treatment of said player. I also authorize release of information to appropriate people (coach, physician) as deemed necessary.

Date