Westman Youth Football Association
Emergency Contacts
Child's name:
Mother's name:
Age:
Home phone:
Date of birth:
DD/MM/YYYY
Email address (please print)
2015 sports
season*
Cell phone:
Medical
conditions:
Father's name:
Allergies:
Home phone:
Current
medications:
Email address (please print)
Cell phone:
Family doctor:
Doctor's
phone:
Family
Provincial
Health #
PHIN #
(individual #)
Alternate contact's name:
Home phone:
Work phone:
Cell phone:
Please CIRCLE the appropriate response below pertaining to your child.
*A new Emergency Contacts sheet must be submitted yearly, and every time information changes.
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
previous history of concussions
fainting episodes during exercise
epileptic
wears glasses
If wears glasses, are lenses shatterproof?
wears contacts
wears dental appliance
hearing problems
asthmatic
trouble breathing during exercise
heart condition
diabetic
has had an illness lasting more than a week in the past year
Yes
Yes
Yes
Yes
No
No
No
No
Yes
Yes
Yes
Yes
No
No
No
No
medication
allergies
wears a medic alert bracelet or necklace
does your child have any health problem that would
interfere with participating on a football team?
surgery in the last 12 months
has been in hospital in the last 12 months
has had injuries requiring medical attention in the past 12 months
presently injured
Please give details below if you answered "YES" to any of the above items
**Any medical condition or injury problem should be checked by your physician
before participating in a football program.
I understand that it is my responsibility to keep Westman Youth Football advised
of any change in the above information as soon as possible, and that in the event
no one can be contacted, Westman Youth Football will take my child to hospital if
deemed necessary.
I hereby authorize the physician and nursing staff to undertake examination,
investigations and necessary treatment of my child.
I also authorize release of information to appropriate people (Coach, Physician) as
deemed necessary.
Date: ___________________
_________________________________
Signature of Parent or Guardian