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Name: _____________________________________________________________________________

 
Date of birth:           Day________________Month_______________Year
 
Address: ___________________________________________________________________________
 
Postal Code: ____________________Telephone (________) ______________________________
 
Mother’s Name___________________________________

 

Father’s Name____________________________________
 
Business Telephone Numbers: 

Mother____________________________Father___________________________
 
Alternate emergency contact (if parents are not available)
 
Name: __________________________________________Telephone: _____________________________

 
Address: _________________________________________________________________________________

 
Doctor’s Name: ___________________________________Telephone (______) _____________________
 

 

Dentist’s Name: __________________________________ Telephone (______) _____________________
 

 

Date of last complete physical examination: _____________________________________

**Before a player participates in a lacrosse program, any medical condition or
injury problem should be checked by that individual’s family physician.
 
Please circle the appropriate response and provide details below if you answer
“Yes: to any of the questions.
                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            Hear Condition
                Yes         No            Diabetic – Type 1_______Type 2_________
                Yes         No            Medication
                Yes         No            Allergies
                Yes         No            wears a medical information bracelet or necklace
                                                For What purpose?  ____________________________
                Yes         No            Has any health problem that would interfere with participation on a lacrosse team
                Yes         No            Has had an illness that lasted more than a week and required medical attention in the past year
                Yes         No            Has had injuries requiring medical attention in the past year
                Yes         No            Has been admitted to hospital in the last year
                Yes         No            Surgery in the last year
                Yes         No            Presently injured.  Injured boy part: __________________
                Yes         No            Vaccinations up to date
                                              Date of last Tetanus Shot: __________________________
                Yes         No            Hepatitis B Vaccination
 
Please give details if you answered “Yes” to any of the above.  Use separate
sheet if necessary
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
 
Medications: _______________________________________________________________________
 
Allergies: __________________________________________________________________________
 
Medical conditions: _________________________________________________________________
 
Recent injuries: _____________________________________________________________________
 
Any information not covered above: __________________________________________________
 
I understand that it is my responsibility to keep the team Lacrosse Trainer 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) is deemed necessary.
 
Date: ______________Signature of Parent or Guardian: ___________________________________
 
Disclaimer:  Personal information used, disclosed, secured or retained will be held solely for the purposes for which it is collected and in accordance with the National Privacy Principles contained in the Personal Information Protection and Electronic Documents Act.