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
City: Postal Code:
Mother's Name: Father's Name:
Mother's Bus. Phone: Father's Bus. Phone:
Doctor's Name: Doctor's Phone:
Dentist's Name: Dentist's Phone:
Please choose 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 Has had an illness lasting more than a week in the past year
Yes No Medication
Yes No Allergies
Yes No Wears a medic alert bracelet or necklace.
Yes No Does your child have any health problem that would interfere with participation on a hockey team?
Yes No Surgery in the last year.
Yes No Has been in hospital in the last year
Yes No Has had injuries requiring medical attention in the past year
Yes No Presently injured
Please give details below if you answered "Yes" to any of the above items.
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: