Players Medical Form
The following is required information from Hockey Canada for the participation in Banff Minor Hockey Association Programs 
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Team *
Required
Athletes First Name *
Athletes Last Name *
Athletes Date of Birth *
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/
DD
/
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Address *
Postal Code *
Provincial Health Number
Telephone Number
Caregiver 1 Name (First/Last) *
Caregiver 1 Phone Number *
Caregiver 2 Name (First/Last) *
Caregiver 2 Phone Number *
Emergency Contact Name (First/Last) *
Emergency Contact Phone Number *
Doctor Name *
Doctors Phone Number *
Dentists Name *
Dentists Phone Number *
  Previous history of concussions   *
Required
Fainting episodes during exercise *
Required
Epileptic *
Required
Wears glasses *
Required
Are lenses shatterproof? *
Required
Wears contact lenses *
Required
Wears dental appliance *
Required
Hearing problem *
Required
Asthma *
Required
Trouble breathing during exercise *
Required
Heart Condition *
Required
Diabetic *
Required
Has had an illness lasting more than a week in the past year *
Required
Medication *
Required
Allergies *
Required
Wears a medic alert bracelet or necklace. *
Required
Does your child have any health problem that would interfere with participation on a hockey team? *
Required
Does your child have any health problem that would interfere with participation on a hockey team? *
Required
Surgery in the last year. *
Required
Has been in hospital in the last year. *
Required
Has had injuries requiring medical attention in the past year *
Required
Presently injured. *
Required
  Please give details below if you answered “Yes” to any of the above items.  
Medications (please list below)
Allergies  (please list below)
Medical Conditions  (please list below)
Recent Injuries  (please list below)
Last Tetanus Shot *
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/
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Any additional information not covered above:
Date of last complete physical exam *
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/
DD
/
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  * 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.   *
Required
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