Emergency Contact and Medical Form

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Please complete the following form so we know how to help you and/or who to contact in case a medical issue arises. This information will be held in the strictest confidence and remain private; will only be shared with the relevant members of the leadership team should an emergency arise while at a club practice/game/event/trip.

Email *

Name *

Birthday *

BC CareCard Number (or equivalent) *

Emergency Contact #1 (Name, relation, and Phone #) *

Emergency Contact #2 (Name, relation, and Phone #)

Any medical issues the leadership team need to be aware of and how we can help you should it happen.( For example a Lung/Heart condition you take a puffer or other medication for, seizures or other neurological disorder you do or don’t take daily/emergency medication for, any allergies or sensitivities requiring an Epi-Pen or other medication, or other significant sports injuries, surgeries, or conditions you have been treated for; cancer, serious infections, or others) All answers will be treated as confidential.

Are you Covid-19 Vaccinated? *

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