Emergency Contact and Medical Form
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.
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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?
Yes - Partially (1st Dose)
Yes - Fully (2nd Dose or “1 and done”)
I am choosing not to get vaccinated
I choose to not answer
Send me a copy of my responses.
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