MEDICAL FORM - DRIVE NORTH BASKETBALL
Please complete and submit the following Medical questionnaire for your child's participation in Drive North Basketball Academy Programs.
Email address *
Program - check all that apply
PARTICIPANT PERSONAL INFORMATION
Complete this section starting with the participant's name.
LName
Your answer
FName
Your answer
DOB
MM
/
DD
/
YYYY
Address
Your answer
Ontario Health Card (optional)
Your answer
Parent 1 / Guardian 1 (first & last names)
Your answer
Phone 1
Your answer
Parent 2 / Guardian 2
Your answer
Phone 2
Your answer
Emergency Contact Name
Your answer
Emergency Contact Number
Your answer
MEDICAL INFORMATION
The Medical information collected on this form will be used only for the purpose of insuring participant safety. This info will remain confidential at all times.
1. Does the participant have a medical condition(s) that Drive North Staff should be aware of?
If yes, please list
Your answer
2. Has the participant ever sustained a concussion?
If yes, please list number, severity and date of last concussion.
Your answer
3. Does the participant have any allergies?
If yes, please list:
Your answer
4. Does the participant take any prescription drugs that would impact the performance required for athletic participation.
If yes, state medication, dosage, frequency:
Your answer
5. Does the participant wear eyeglasses?
6. Does the participant wear contact lenses?
A copy of your responses will be emailed to the address you provided.
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