2019 Medical Information for Red Devils Cycling Academy
Childs Basic information
First Name *
Your answer
Last Name *
Your answer
Date or Birth *
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Childs Medical information
BC Provincial Health Number *
Your answer
Doctors name *
Your answer
Doctors phone number *
Your answer
Dentist name *
Your answer
Dentist phone number *
Your answer
Address *
Your answer
Parent and emergency contact information
Mothers Name *
Your answer
Mothers phone number *
Your answer
Fathers Name *
Your answer
Fathers phone number *
Your answer
emergency contact if parents cannot be reached *
Your answer
emergency contacts phone number *
Your answer
Medical history questions
previous history of concussion *
fainting episodes during exercise *
epileptic *
wears glasses *
are lenses shatter proof? *
wears contact lenses *
wears dental appliance *
hearing problem *
asthma *
trouble breathing during exercise *
heart condition *
diabetic *
medication *
allergies *
wears a medical alert bracelet or necklace *
surgery in the last year *
has been in the hospital in the last year *
has had injuries in the last year requiring medical attention *
has a health problem that would interfere with participation in sports *
Give details if answered yes to any of the above questions
Your answer
medications
Your answer
allergies
Your answer
last tetanus shot *
MM
/
DD
/
YYYY
last complete physical exam *
MM
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DD
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YYYY
any other information not covered on this form
Your answer
Final signature
I understand that it is my responsibility as a parent to inform head coach of any medical changes *
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YYYY
I here by authorize Red Devils Cycling Academy coaches to call emergency services on behalf of my child in the event of an incident that the deem it necessary. (please type your full name) *
Your answer
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