Medical form 
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Athlete Name *
Date of Birth (MM/DD/YY) *
Address *
Phone number (of parent/guardian) *
Health Card No.
E-mail contact *
Text/cell contact (or the best way to get a hold of you quickly)! *
Emergency Contact #1 - Name *
Emergency Contact #1 - Phone number(s)  *
Emergency Contact #2 - Name *
Emergency Contact #2 - Phone number(s)  *
REQUEST TO PARTICIPATE/INFORMED CONSENT AGREEMENT. I request our son/daughter/ward participate in the Haliburton Summer Track Club *
I have read and signed the attached waiver and comprehend and accept the risks involved in participating in Track and Field and assume responsibility for my son/daughter/ward and their personal health, medical, dental and accident insurance coverages. *
MEDICAL HISTORY: (please provide any pertinent details about past injuries, medical conditions, allergies, including any history of concussion) *
Please provide any details about prescription drugs your son/daughter/ward takes regularly. *
Please indicate if you would like a coach to phone you regarding any of these health concerns for further discussion. *
Does your son/daughter/ward wear eyeglasses? *
Does your son/daughter/ward wear contact lenses? *
Does your son/daughter/ward wear orthodontic appliances? *
Medical Services Authorization (Optional)
In a situation where emergency medical or hospital services are required by the above listed participant, and with the understanding that every reasonable effort will be made by the coach/hospital to contact me, my agreement on this form authorize medical personal and/or hospital to administer medical and/or surgical services, including anesthesia and drugs. I understand that any cost will be my responsibility. 
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