Medical Sheet (Tillsonburg Minor Hockey Inc.)

PrintMedical Sheet

Tillsonburg Minor Hockey Inc. Player Medical Information Sheet
(This form can also be printed and filled in manually)

Last Name: First Name:
Date of Birth: Day Month Year
Address 1:.
Address 2:.
City: Postal Code:
Phone Number:
Mother's Name: Father's Name:
Mother's Bus. Phone: Father's Bus. Phone:

Emergency Contacts
Name: Phone:
Doctor's Name: Doctor's Phone:
Dentist's Name: Dentist's Phone:

Please choose the appropriate response below pertaining to your child

Previous history of concussions

Fainting episodes during exercise


Wears glasses

Are lenses shatterproof

Wears contact lenses

Wears dental appliance

Hearing problem


Trouble breathing during exercise

Heart Condition


Has had an illness lasting more than a week in the past year



Wears a medic alert bracelet or necklace.

Does your child have any health problem that would interfere with participation on a hockey team?

Surgery in the last year.

Has been in hospital in the last year

Has had injuries requiring medical attention in the past year

Presently injured

Please give details below if you answered "Yes" to any of the above items.

Medical conditions:
Recent Injuries:
Last Tetanus Shot:
Any information not covered above:
Date of last complete physical examination:

Any medical condition or injury problem should be checked by your physician
before participating in a hockey program.
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 my child to hospital/M.D. 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)
as deemed necessary.

Signature of Parent or Guardian: