Name:
Date of Birth: Day:
Address:
Postal Code:
Provincial Health Number:
Mother’s Name:
2 nd and / or work number:
Father’s Name:
Month:
Tel:
Mother’s number:
Father’s number:
Year:
2 nd and / or work number:
Person to contact in case of an emergency, if player’s parents are not available:
Name: Tel:
Doctor’s Name:
Dentist’s name:
Tel:
Tel:
Please circle the appropriate response below pertaining to your child
Yes No
Yes No
Yes No
Previous history of concussions
Fainting episodes during exercise
Epileptic
Yes No Wears glasses
Yes No Wears contact lenses
Yes No Wears a dental appliance
Yes No Hearing problems
Yes No Asthma
Yes No Trouble breathing during exercise
Yes No Heart condition
Yes No Diabetic
Yes No Medication
Yes No Allergies
Yes No Blood born pathogens (Hep. C, HIV, etc.)
Yes No Wears a medic alert bracelet or necklace
Yes No Does your child have any health problems that would interfere with participation on a football team?
Yes No Surgery in the last year
Yes No Has been in the hospital in the last year.
Yes No Has had injuries requiring medical attention during the past year
Yes No Presently injured

Please give details if you answered yes to any of the above items.
Use separate sheet if necessary
Medications:
Allergies:
Medical Conditions:
Recent Injuries:
Last tetanus Shot:
Any information not covered above: ____________________________________________
A full physical examination is required for students playing on a S.D.S.S. Football team, it is a requirement for South Delta Secondary School for athletes participating in full contact sports such as Football.
The above named student has seen a physician and is considered physically fit to participate in the sport of Football for the year of _____________.
Date of complete physical:___________________________________________________
Any medical condition or injury should be checked by your Doctor before continued participation in the football 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 the hospital/MD 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.
Signature of Parent or Guardian:
Date: