Hockey Canada 



MEDICAL INFORMATION SHEET 


Name: ________________________________________________________________________________ 
Date of birth: Day ___________ Month ___________ Year ___________ 
Address: ______________________________________________________________________________ 
Postal Code: _______________ Telephone: ( ____ ) _______________________ 
Provincial Health Number (optional): __________________________________________________________ 
Mother’s Name:______________________________ Father’s Name: _______________________________ 
Business Telephone Numbers: Mother _________________________ Father _________________________ 
Alternate emergency contact (if parents are not available) 
Name: _________________________________________________ Telephone: _____________________ 
Address: ______________________________________________________________________________ 
Doctor’s Name: ______________________________________ Telephone: ( ____ ) ___________________ 
Dentist’s Name: ______________________________________ Telephone: ( ____ ) ___________________ 
Date of last complete physical examination: ___________________________ 

* Before a player participates in a hockey program, any medical condition or injury problem should be checked by 
that individual’s family physician. 
Please circle the appropriate response and provide details below if you answer “Yes” to any of the questions. 
Yes No Previous history of concussions 
Yes No Fainting episodes during exercise 
Yes No Epileptic 
Yes No Wears glasses 
Yes No Are lenses shatterproof 
Yes No Wears contact lenses 
Yes No Wears dental appliance 
Yes No Hearing problem 
Yes No Asthma 
Yes No Trouble breathing during exercise 
Yes No Heart Condition 
Yes No Diabetic – Type 1_____ Type 2_______ 
Yes No Medication 
Yes No Allergies 

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Yes No Wears a medical information bracelet or necklace 
For what purpose? __________________ 
Yes No Has any health problem that would interfere with participation on a hockey team 
Yes No Has had an illness that lasted more than a week and required medical attention in the 
past year 
Yes No Has had injuries requiring medical attention in the past year 
Yes No Has been admitted to hospital in the last year 
Yes No Surgery in the last year 
Yes No Presently injured. Injured body part: ________________ 
Yes No Vaccinations up to date 
Date of last Tetanus Shot:_____________ 
Yes No Hepatitis B vaccination 

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

Medications:____________________________________________________________________________ 
Allergies: ______________________________________________________________________________ 
Medical conditions: ______________________________________________________________________ 
Recent injuries: _________________________________________________________________________ 
Any information not covered above: __________________________________________________________ 
I understand that it is my responsibility to keep the team Safety Person 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. 


Date:____________________Signature of Parent or Guardian: ______________________________________ 


Disclaimer: Personal information used, disclosed, secured or retained by Hockey Canada 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 Hockey Canada’s own 
Privacy Policy. 

Hockey Canada Safety Program