MEDICAL AND WAIVER FORM

 

First Name:

 

Last Name:

 

Date of Birth (MM/DD/YY)

 

Gender:

Male
Female

 

Address:

 

City/Town:

 

Province/State:

 

Postal Code/Zip

 

Parent/Guardian:

 

E-Mail:

 

Home Phone:

 

Work Phone:

 

Other Phone:

 

Provicial Health Number:

 

Allergies:

YES
NO

 

If YES Describe:

 

Have you had any of the following Health issues? (Please check if YES)

Diabetes
Heart
Epilepsy
Kidney

 

Explain:

 

Do you take any medications for Asthma?

YES
NO

 

Have you been recently hospitalized for Asthma?

YES
NO

 

Other medications currently taking:

 

Dosages:

 

Recent Injuries (Please check any that apply):

Fractures
Dislocations
Sprains/Strains
Hospitalizations
Surgery

 

Date of last injury (MM/DD/YY)

 

Please explain:

 

Do you wear eye glasses?

YES
NO

 

Do you wear contact lenses?

YES
NO

 

Hearing problems?

YES
NO

 

Special Diet:

 

Date of last Tetanus shot (MM/DD/YY)

 

Other Comments:

 

Family Physician:

 

Address:

 

Phone Number: