Rockwood FC Medical Form

 

    Gender:
    femalemale




    Person to contact in case of Emergency, if parents are not available


    Medical Data

    Previous history of concussions
    yesno

    Fainting episodes during exercise
    yesno

    Epileptic
    yesno

    Wear glasses
    yesno
    If yes, are they shatterproof
    yesno

    Wears contact lenses
    yesno

    Wears dental appliance
    yesno

    Hearing Problem
    yesno

    Asthma
    yesno

    Trouble breathing during exercise
    yesno

    Heart condition
    yesno

    Diabetic
    yesno

    Medical alert bracelet
    yesno

    Uses Medication
    yesno

    Allergies
    yesno

    What you are signing for:

    • Any medical condition or injury problem should be checked by your physician before participating in a Soccer program.
    • I understand that it is my responsibility to keep the team management advised of any changes in the above information and notify them as soon as possible. In the event no one can be contacted in the case of a medical emergency, team management will take my child to a hospital/M.D. 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 persons as deemed necessary.