Name *

First Name

Last Name

Phone *

(###)

###

####

Any history of concussion *

Yes

No

Any fainting episodes during exercises? *

Yes

No

Epileptic *

Yes

No

Wear any corrective eyewear? *

Yes

No

If you wear corrective eyewear, are they waterproof / shatterproof ?

Yes

No

Wear any dental appliance? *

Yes

No

Have any hearing impairments? *

Yes

No

Asthmatic or any breathing impairments? *

Yes

No

Has any trouble breathing during exercises? *

Yes

No

Any heart conditions? *

Yes

No

Diabetic? *

Yes

No

Require to take any regular medication? (ongoing or not) *

Yes

No

Wears any medical alert bracelet or necklace? *

Yes

No

Does your child have any health issues that would interfere with participation in a hockey program? *

Yes

No

Has had any surgery in the past year? *

Yes

No

Has been in the hospital in the last year? *

Yes

No

Has had any injuries that required medical attention in the past year? *

Yes

No

Currently injured? *

Yes

No