ODMLA (Northmen) Participant Medical Information Card

Name: ________________________________

 

Date of Birth: _________  /____________  /__________________

                                  Day                   Month                        Year

 
 

Person to be contacted in case of emergency:

 
____________________________________________________________

 

Phone numbers:  Day__________________    Evening________________________

 

Alternative Contact:

__________________________________________________________________________

 

Phone numbers:  Day__________________   Evening________________________

 

Family Doctor Name: __________________________________

 

Family Doctor Phone Number: ________________________________

 

Medical Insurance Number (OHIP etc)

___________________________________________________________________

 

Relevant Medical History                            

 

Medications: ______________________________________________

 

Allergies: _____________________________________________________________

 

Previous Injuries: __________________________________________________________

 

Other Conditions: ________________________________________________________

                                                                               

Braces, Contact Lenses, Glasses etc: _________________________________________

 

Does participant carry and know how to administer his or her own medications?

 

Yes: _________No_____________

 

Note: All information is confidential.  Keep this card with the team at all times... These cards will only be available to authorized individuals.