Medical Form 2017-03-09T12:14:54+00:00

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.