Player Medical Information Sheet, PeeWee LL2, U12/13, 2016-2017 (Welland Minor Hockey)

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This Team is part of the 2016-2017 season, which is not set as the current season.
Player Medical Information Sheet
Please provide as much information as possible to help the team staff with any medical issues and/or emergencies. This information will be kept confidential between the team staff and the player's family.
This form has a limit of 16 submissions. At the moment this page loaded, 11 submissions have been submitted. It is possible that not all submissions have been validated at this time, and more openings could become available. However, at this time only 5 more submissions will be accepted.

Contact Information

Before a player participates in a hockey program it is recommended that they have a medical and that they also have any medical condition or injury problem checked by their family physician

Medical Information

Please check the appropriate response and provide details below if you answer “Yes” to any of the questions.

Details:

Please give details if you answered “Yes” to any of the above. (Use separate sheet if necessary)

Agreement

I understand that it is my responsibility to keep the team Safety Person (Trainer) advised of any change in the above information as soon as possible. In the event of a medical emergency and that no one can be contacted; team management will arrange to take my child to the hospital or a physician 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.

Disclaimer: Personal information used, disclosed, secured or retained by Welland Minor Hockey Association (WMHA) will be held solely for the purposes for which we collected it and in accordance with the National Privacy Principles contained in the Personal Information Protection and Electronic Documents Act as well as WMHA’s own Privacy Policy.

This form has a limit of 16 submissions. At the moment this page loaded, 11 submissions have been submitted. It is possible that not all submissions have been validated at this time, and more openings could become available. However, at this time only 5 more submissions will be accepted.